Healthcare Provider Details

I. General information

NPI: 1346083326
Provider Name (Legal Business Name): KHUE PHAM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2024
Last Update Date: 01/27/2025
Certification Date: 01/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1630 PLEASANT HILL RD
DULUTH GA
30096-5899
US

IV. Provider business mailing address

5800 CARLTON WAY
STONE MOUNTAIN GA
30087-2700
US

V. Phone/Fax

Practice location:
  • Phone: 770-381-7878
  • Fax:
Mailing address:
  • Phone: 404-723-1951
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN123526
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: