Healthcare Provider Details

I. General information

NPI: 1194491738
Provider Name (Legal Business Name): MARY R PHAM DDS DENTAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/23/2021
Last Update Date: 08/25/2021
Certification Date: 08/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12751-21771 LAKE FOREST LANE DR. SUITE 21
LAKE FOREST CA
92630
US

IV. Provider business mailing address

1041 E YORBA LINDA BLVD STE 206
PLACENTIA CA
92870-3763
US

V. Phone/Fax

Practice location:
  • Phone: 714-528-8252
  • Fax:
Mailing address:
  • Phone: 714-528-8252
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. MARY REGINA PHAM
Title or Position: CEO/PEDIATRIC DENTIST
Credential: D.D.S
Phone: 714-528-8252