Healthcare Provider Details

I. General information

NPI: 1871351825
Provider Name (Legal Business Name): PHAN HUYNH DDS MS APC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2024
Last Update Date: 03/13/2024
Certification Date: 03/13/2024
Deactivation Date:
Reactivation Date:

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: 626-841-9347
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. PHAN HUYNH
Title or Position: CEO
Credential: DDS, MS
Phone: 626-841-9347