Healthcare Provider Details

I. General information

NPI: 1013479518
Provider Name (Legal Business Name): PAULINE PHAM DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/03/2019
Last Update Date: 07/17/2025
Certification Date: 07/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 S PAULINA ST
CHICAGO IL
60612-7210
US

IV. Provider business mailing address

855 W MADISON ST APT 912
CHICAGO IL
60607-3138
US

V. Phone/Fax

Practice location:
  • Phone: 312-355-1222
  • Fax:
Mailing address:
  • Phone: 408-829-5490
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number018.002298
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number018.002298
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: