Healthcare Provider Details

I. General information

NPI: 1164986220
Provider Name (Legal Business Name): MARY R. PHAM, D.D.S., INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/23/2019
Last Update Date: 01/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2750 HARBOR BLVD # B-06
COSTA MESA CA
92626-5121
US

IV. Provider business mailing address

2750 HARBOR BLVD # B-06
COSTA MESA CA
92626-5121
US

V. Phone/Fax

Practice location:
  • Phone: 334-657-7668
  • Fax:
Mailing address:
  • Phone: 334-657-7668
  • Fax:

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: DR. PAUL PHAM
Title or Position: MANAGER
Credential: PHARMD.
Phone: 334-657-7668