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General NPI Number Information
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NPI Number | 1306332325
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Entity Type | Individual
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Provider Name | NATHANIEL PHEN DMD
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Gender | Male
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Dates
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Enumeration Date | 07/02/2018
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Last Update Date | 07/02/2018
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Provider Practice Location Address
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Address Line | 2202 S W S YOUNG DR STE 102
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City | KILLEEN
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State | TX
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Zip | 76543-5318
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Country | US
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Telephone | 254-523-0934
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Fax |
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Provider Business Mailing Address
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Address Line | 1400 WESTINGHOUSE RD # 1213
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City | GEORGETOWN
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State | TX
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Zip | 78626-2174
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Country | US
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Telephone | 863-370-5061
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 34291
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License Number State | TX
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