Healthcare Provider Details

I. General information

NPI: 1164662789
Provider Name (Legal Business Name): QUY-PHUNG THI PHAN D.D.S
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/22/2009
Last Update Date: 02/22/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

628 RUNNING DEER RD
WALNUT CA
91789-4299
US

IV. Provider business mailing address

628 RUNNING DEER RD
WALNUT CA
91789-4299
US

V. Phone/Fax

Practice location:
  • Phone: 626-581-8209
  • Fax:
Mailing address:
  • Phone: 626-581-8209
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number50090
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: