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General NPI Number Information
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NPI Number | 1598347510
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Entity Type | Organization
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Legal Business Name | COSTA MESA ORAL SURGERY
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Dates
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Enumeration Date | 04/28/2021
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Last Update Date | 04/28/2021
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Provider Practice Location Address
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Address Line | 2900 BRISTOL ST STE D101
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City | COSTA MESA
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State | CA
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Zip | 92626-5939
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Country | US
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Telephone | 562-598-4683
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Fax |
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Provider Business Mailing Address
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Address Line | 4582 KATELLA AVE
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City | LOS ALAMITOS
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State | CA
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Zip | 90720-2655
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Country | US
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Telephone | 310-849-4690
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Fax | 562-598-4693
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Authorized Official
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Title or Position | OWNER, PARTNER
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Name | DR. LEE DUONG PHAM
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Credential | DDS, MD
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Telephone | 310-849-4690
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number |
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License Number State |
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