Healthcare Provider Details

I. General information

NPI: 1023001922
Provider Name (Legal Business Name): DERYCK PHAM D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2005
Last Update Date: 08/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

447 S SHORE RD
MARMORA NJ
08223-1292
US

IV. Provider business mailing address

447 S SHORE RD
MARMORA NJ
08223-1292
US

V. Phone/Fax

Practice location:
  • Phone: 609-390-0111
  • Fax:
Mailing address:
  • Phone: 609-390-0111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number052396-1
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number02355500
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: