Healthcare Provider Details

I. General information

NPI: 1427402908
Provider Name (Legal Business Name): PHAN XUAN HUYNH DDS, MS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/20/2016
Last Update Date: 03/27/2024
Certification Date: 03/27/2024
Deactivation Date: 06/13/2018
Reactivation Date: 09/25/2020

III. Provider practice location address

7056 ARCHIBALD AVE STE 105
EASTVALE CA
92880-8714
US

IV. Provider business mailing address

12268 OLDENBERG CT
RANCHO CUCAMONGA CA
91739-9037
US

V. Phone/Fax

Practice location:
  • Phone: 951-407-1119
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDDS104727
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: