Healthcare Provider Details

I. General information

NPI: 1578944294
Provider Name (Legal Business Name): HIEU NGOC PHAN DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/18/2015
Last Update Date: 06/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

533 W CHURCH ST
BATESBURG-LEESVILLE SC
29006-1706
US

IV. Provider business mailing address

1517 HATHAWAY DR
ROCK HILL SC
29730-8966
US

V. Phone/Fax

Practice location:
  • Phone: 803-532-3331
  • Fax:
Mailing address:
  • Phone: 803-397-9115
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDGD.8561 GD
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: