=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225481138
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NGOC PHAM DMD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/15/2016
-----------------------------------------------------
Last Update Date | 07/25/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7861 GREENBACK LN
-----------------------------------------------------
City | CITRUS HEIGHTS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95610
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-609-9714
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5116 PERTH GLEN DR
-----------------------------------------------------
City | ANTELOPE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95843-5942
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-609-9714
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 31972
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 102833
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------