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General NPI Number Information
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NPI Number | 1144656406
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Entity Type | Organization
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Legal Business Name | THI PHAN DENTAL CORP
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Dates
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Enumeration Date | 09/18/2013
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Last Update Date | 09/18/2013
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Provider Practice Location Address
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Address Line | 1540 FERN ST
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City | SAN DIEGO
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State | CA
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Zip | 92102-1536
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Country | US
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Telephone | 619-236-9549
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Fax | 619-234-0311
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Provider Business Mailing Address
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Address Line | 1540 FERN ST
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City | SAN DIEGO
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State | CA
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Zip | 92102-1536
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Country | US
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Telephone | 619-236-9549
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Fax | 619-234-0311
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Authorized Official
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Title or Position | PRESIDENT/OWNER
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Name | THI BINH PHAN
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Credential | DDS
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Telephone | 619-236-9549
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | 40484
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License Number State | CA
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