Healthcare Provider Details

I. General information

NPI: 1972228831
Provider Name (Legal Business Name): ANDREW CHRISTOPHER PHAM DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2022
Last Update Date: 10/04/2022
Certification Date: 10/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

712 JAY ST
FOSSIL OR
97830-8371
US

IV. Provider business mailing address

14730 SE FRYE ST
HAPPY VALLEY OR
97086-2837
US

V. Phone/Fax

Practice location:
  • Phone: 541-723-2725
  • Fax:
Mailing address:
  • Phone: 971-533-9161
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD11600
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: