Healthcare Provider Details

I. General information

NPI: 1245827377
Provider Name (Legal Business Name): MARY PHAM DDS DENTAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/22/2020
Last Update Date: 02/03/2022
Certification Date: 02/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13931 CARROLL WAY STE C
TUSTIN CA
92780-1861
US

IV. Provider business mailing address

2750 HARBOR BLVD STE B6
COSTA MESA CA
92626-5121
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: DDS MS
Phone: 714-528-8252