Healthcare Provider Details

I. General information

NPI: 1003264821
Provider Name (Legal Business Name): CHI-LAN PHAM D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/02/2016
Last Update Date: 09/09/2021
Certification Date: 09/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4200 WISCONSIN AVE NW STE 240
WASHINGTON DC
20016-2175
US

IV. Provider business mailing address

4200 WISCONSIN AVE NW STE 240
WASHINGTON DC
20016-2175
US

V. Phone/Fax

Practice location:
  • Phone: 202-545-7200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number019.031604
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberDEN1002122
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: