Healthcare Provider Details

I. General information

NPI: 1215632070
Provider Name (Legal Business Name): BINH THANH PHAN DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2023
Last Update Date: 06/05/2023
Certification Date: 06/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12165 ELM STREET
PRINCESS ANNE MD
21853-1358
US

IV. Provider business mailing address

PO BOX 1978
SALISBURY MD
21802-1978
US

V. Phone/Fax

Practice location:
  • Phone: 410-651-5151
  • Fax: 410-651-4256
Mailing address:
  • Phone: 410-749-1015
  • Fax: 410-749-0654

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberLL917
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: