Healthcare Provider Details

I. General information

NPI: 1205135522
Provider Name (Legal Business Name): ELIZABETH PHAM ODELL DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ELIZABETH PHAM

II. Dates (important events)

Enumeration Date: 03/25/2011
Last Update Date: 08/12/2024
Certification Date: 08/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2778 TEAYS VALLEY RD
HURRICANE WV
25526
US

IV. Provider business mailing address

2778 TEAYS VALLEY RD
HURRICANE WV
25526
US

V. Phone/Fax

Practice location:
  • Phone: 681-233-4025
  • Fax: 681-233-4039
Mailing address:
  • Phone: 681-233-4025
  • Fax: 681-233-4039

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number4042
License Number StateWV
# 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: