Healthcare Provider Details

I. General information

NPI: 1174074496
Provider Name (Legal Business Name): SD- 4315FREDERICK PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/21/2016
Last Update Date: 12/17/2021
Certification Date: 12/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4522 FREDERICKSBURG RD A28
SAN ANTONIO TX
78201-6547
US

IV. Provider business mailing address

10901 GARLAND RD
DALLAS TX
75218-2613
US

V. Phone/Fax

Practice location:
  • Phone: 210-530-8841
  • Fax: 210-530-8738
Mailing address:
  • Phone: 214-466-1400
  • Fax: 214-367-5896

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number19887
License Number StateTX

VIII. Authorized Official

Name: DR. LYNHTHY THY PHAM
Title or Position: PRESIDENT
Credential: DDS
Phone: 214-718-6052