Healthcare Provider Details

I. General information

NPI: 1366014375
Provider Name (Legal Business Name): CHIEU PHAM DENTAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/11/2021
Last Update Date: 07/11/2021
Certification Date: 07/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2015 BIRCH ROAD STE 103
CHULA VISTA CA
91915
US

IV. Provider business mailing address

2015 BIRCH ROAD STE 103
CHULA VISTA CA
91915
US

V. Phone/Fax

Practice location:
  • Phone: 619-421-5437
  • Fax: 619-924-8494
Mailing address:
  • Phone: 619-421-5437
  • Fax: 619-924-8494

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: CHIEU PHAM
Title or Position: OWNER
Credential: DDS
Phone: 619-421-5437