=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134103005
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DAT VAN PHAM DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/02/2005
-----------------------------------------------------
Last Update Date | 02/19/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 403 W. GRAND PARKWAY S. SUITE H
-----------------------------------------------------
City | KATY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77494-6606
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-402-8188
-----------------------------------------------------
Fax | 281-402-8190
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 403 W GRAND PKWY S STE H
-----------------------------------------------------
City | KATY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77494-8358
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-402-8188
-----------------------------------------------------
Fax | 281-402-8190
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number | 25911
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 25911
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 25911
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------