Healthcare Provider Details

I. General information

NPI: 1508353731
Provider Name (Legal Business Name): HUNG QUOC PHAM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/13/2018
Last Update Date: 06/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 N MEDICAL DR
SALT LAKE CITY UT
84132-0001
US

IV. Provider business mailing address

2263 W AUGUST FARMS CIR
WEST VALLEY UT
84119-6044
US

V. Phone/Fax

Practice location:
  • Phone: 385-202-9721
  • Fax:
Mailing address:
  • Phone: 385-202-9721
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number11263872-9922
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: