Healthcare Provider Details

I. General information

NPI: 1649877994
Provider Name (Legal Business Name): DONALD PHAM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/08/2020
Last Update Date: 10/08/2020
Certification Date: 10/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9907 WALKER ST
CYPRESS CA
90630-3827
US

IV. Provider business mailing address

13611 ILLINOIS ST
WESTMINSTER CA
92683-2635
US

V. Phone/Fax

Practice location:
  • Phone: 714-581-8585
  • Fax:
Mailing address:
  • Phone: 714-655-8604
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDDS105531
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: