Healthcare Provider Details

I. General information

NPI: 1013934041
Provider Name (Legal Business Name): DAI CHINH PHAN DDS, MS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 SAN PEDRO DR SE
ALBUQUERQUE NM
87108-5153
US

IV. Provider business mailing address

12025 SULLIVAN CT NW
ALBUQUERQUE NM
87114-6535
US

V. Phone/Fax

Practice location:
  • Phone: 505-256-2778
  • Fax:
Mailing address:
  • Phone: 505-256-2778
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number6032
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: