Healthcare Provider Details

I. General information

NPI: 1942662457
Provider Name (Legal Business Name): PHAN, RAWLINS & LYONS DDS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/23/2016
Last Update Date: 03/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6942 ALMADEN EXPY # 11
SAN JOSE CA
95120-3201
US

IV. Provider business mailing address

PO BOX 4785
EL DORADO HILLS CA
95762-0024
US

V. Phone/Fax

Practice location:
  • Phone: 480-235-8541
  • Fax:
Mailing address:
  • Phone: 916-229-9941
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number56958
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number51968
License Number StateCA

VIII. Authorized Official

Name: JOSEPH RAWLINS
Title or Position: PRESIDENT
Credential: DDS
Phone: 916-229-9941