Healthcare Provider Details

I. General information

NPI: 1366917353
Provider Name (Legal Business Name): QUYNH VO BAO PHAM DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2018
Last Update Date: 10/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3767 AVOCADO BLVD
LA MESA CA
91941-7301
US

IV. Provider business mailing address

10812 PACIFIC CANYON WAY
SAN DIEGO CA
92121-4337
US

V. Phone/Fax

Practice location:
  • Phone: 619-729-2323
  • Fax:
Mailing address:
  • Phone: 310-720-5024
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDDS102880
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: