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General NPI Number Information
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NPI Number | 1174070361
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Entity Type | Organization
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Legal Business Name | THAI PHAM DMD PA
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Dates
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Enumeration Date | 09/06/2016
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Last Update Date | 08/26/2022
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Provider Practice Location Address
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Address Line | 13127 KINGS LAKE DR SUITE 101
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City | GIBSONTON
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State | FL
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Zip | 33534-3958
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Country | US
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Telephone | 813-284-7958
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Fax | 813-284-7959
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Provider Business Mailing Address
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Address Line | 13127 KINGS LAKE DR SUITE 101
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City | GIBSONTON
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State | FL
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Zip | 33534-3958
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Country | US
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Telephone | 813-284-7958
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Fax | 813-284-7959
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Authorized Official
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Title or Position | DIRECTOR
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Name | DR. THAI VU PHAM
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Credential | DMD, PHD
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Telephone | 813-802-6849
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223E0200X
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Taxonomy Name | Endodontics
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License Number | DN18558
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License Number State | FL
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