Healthcare Provider Details

I. General information

NPI: 1861646747
Provider Name (Legal Business Name): PHONG CAM TA D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/05/2008
Last Update Date: 06/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 W 53RD ST APT 126
NEW YORK NY
10019-5622
US

IV. Provider business mailing address

410 W 53RD ST APT 126
NEW YORK NY
10019-5693
US

V. Phone/Fax

Practice location:
  • Phone: 215-527-8768
  • Fax:
Mailing address:
  • Phone: 215-527-8768
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberP65701
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code1223D0004X
TaxonomyDental Anesthesiology
License Number054360
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: