Healthcare Provider Details

I. General information

NPI: 1356436570
Provider Name (Legal Business Name): SON G PHAM DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8735 TRAUTWEIN RD
RIVERSIDE CA
92508
US

IV. Provider business mailing address

2860 MICHELLE DRIVE 2ND FLOOR
IRVINE CA
92606
US

V. Phone/Fax

Practice location:
  • Phone: 951-776-1330
  • Fax: 951-776-1388
Mailing address:
  • Phone: 714-508-3600
  • Fax: 714-368-2092

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number49975
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: