Healthcare Provider Details

I. General information

NPI: 1326309329
Provider Name (Legal Business Name): MARY REGINA PHAM D.D.S., M.S. DENTAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/06/2012
Last Update Date: 02/10/2022
Certification Date: 02/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1041 E YORBA LINDA BLVD SUITE 206
PLACENTIA CA
92870-3728
US

IV. Provider business mailing address

1041 E YORBA LINDA BLVD SUITE 206
PLACENTIA CA
92870-3728
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 Number60222
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number58404
License Number StateCA

VIII. Authorized Official

Name: DR. MARY REGINA PHAM
Title or Position: OWNER
Credential: DDS, MS
Phone: 714-528-8252