Healthcare Provider Details

I. General information

NPI: 1316532914
Provider Name (Legal Business Name): JOHNNY DUY PHAM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/04/2021
Last Update Date: 07/28/2026
Certification Date: 07/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19720 BEACH BLVD STE A
HUNTINGTON BEACH CA
92648-2932
US

IV. Provider business mailing address

14852 GIVENS PL
WESTMINSTER CA
92683-5513
US

V. Phone/Fax

Practice location:
  • Phone: 714-593-1010
  • Fax:
Mailing address:
  • Phone: 714-722-8088
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number107364
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number107364
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: