Healthcare Provider Details

I. General information

NPI: 1811160880
Provider Name (Legal Business Name): RICHARD KHOA PHAM DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/10/2008
Last Update Date: 09/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 N ZARAGOZA RD STE T
EL PASO TX
79907-4735
US

IV. Provider business mailing address

3820 CONVOY ST
SAN DIEGO CA
92111-3722
US

V. Phone/Fax

Practice location:
  • Phone: 915-493-2699
  • Fax:
Mailing address:
  • Phone: 858-569-1100
  • Fax: 858-569-2010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number27346
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number57680
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: