Healthcare Provider Details

I. General information

NPI: 1588094908
Provider Name (Legal Business Name): DENNIS H PHAM DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/21/2013
Last Update Date: 04/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

47875 CALEO BAY DR # A101
LA QUINTA CA
92253-6386
US

IV. Provider business mailing address

29 ALICANTE CIR
RANCHO MIRAGE CA
92270-1770
US

V. Phone/Fax

Practice location:
  • Phone: 760-564-1300
  • Fax:
Mailing address:
  • Phone: 720-935-5704
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number100207
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: