Healthcare Provider Details

I. General information

NPI: 1700263779
Provider Name (Legal Business Name): MATTHEW PHAM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/29/2015
Last Update Date: 11/22/2024
Certification Date: 11/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3573 SUNSET BLVD
WEST COLUMBIA SC
29169-3043
US

IV. Provider business mailing address

101 MANNING DR 149 BRAUER HALL,
CHAPEL HILL NC
27514
US

V. Phone/Fax

Practice location:
  • Phone: 803-973-4530
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number10002
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: