Healthcare Provider Details

I. General information

NPI: 1073174637
Provider Name (Legal Business Name): HUONG THU PHAN DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2019
Last Update Date: 08/25/2025
Certification Date: 08/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 W BROAD ST
COLUMBUS OH
43204-3783
US

IV. Provider business mailing address

4419 FALLBROOK BLVD
PALM HARBOR FL
34685-2653
US

V. Phone/Fax

Practice location:
  • Phone: 614-645-2300
  • Fax: 614-645-5517
Mailing address:
  • Phone: 813-420-7005
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberAPP-000261372
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberDN25552
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: