Healthcare Provider Details

I. General information

NPI: 1376190744
Provider Name (Legal Business Name): JENNIFER M. PHAM DMD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2019
Last Update Date: 08/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18 WIRT ST SW
LEESBURG VA
20175-2915
US

IV. Provider business mailing address

42550 STIRES DR
CHANTILLY VA
20152-6655
US

V. Phone/Fax

Practice location:
  • Phone: 703-777-5600
  • Fax:
Mailing address:
  • Phone: 703-629-5088
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. JENNIFER MINH PHAM
Title or Position: PRESIDENT
Credential: DMD
Phone: 703-629-5088