Healthcare Provider Details

I. General information

NPI: 1225873334
Provider Name (Legal Business Name): CINDY PHAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/28/2024
Last Update Date: 08/16/2026
Certification Date: 08/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 KNEELAND ST
BOSTON MA
02111-1527
US

IV. Provider business mailing address

9641 STANFORD AVE
GARDEN GROVE CA
92841-4942
US

V. Phone/Fax

Practice location:
  • Phone: 617-636-6828
  • Fax:
Mailing address:
  • Phone: 714-823-7978
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number113101
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: