Healthcare Provider Details

I. General information

NPI: 1982357281
Provider Name (Legal Business Name): PHAN DENTAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/27/2022
Last Update Date: 01/27/2022
Certification Date: 01/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7048 DUBLIN BLVD
DUBLIN CA
94568-3017
US

IV. Provider business mailing address

150 N JACKSON AVE STE 211
SAN JOSE CA
95116-1908
US

V. Phone/Fax

Practice location:
  • Phone: 925-833-0535
  • Fax:
Mailing address:
  • Phone: 408-251-7901
  • Fax: 408-251-0991

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223X0008X
TaxonomyOral and Maxillofacial Radiology Dentistry
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. H. DERICK PHAN
Title or Position: OWNER
Credential: DDS
Phone: 408-251-7901