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General NPI Number Information
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NPI Number | 1609075910
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Entity Type | Individual
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Provider Name | H. DERICK PHAN D.D.S., C.A.G.S.
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Gender | Male
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Dates
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Enumeration Date | 07/16/2007
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Last Update Date | 07/29/2008
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Provider Practice Location Address
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Address Line | 11040 BOLLINGER CANYON RD SUITE K
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City | SAN RAMON
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State | CA
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Zip | 94582-4959
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Country | US
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Telephone | 925-648-8588
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Fax | 925-648-8008
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Provider Business Mailing Address
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Address Line | 11040 BOLLINGER CANYON RD SUITE K
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City | SAN RAMON
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State | CA
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Zip | 94582-4959
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Country | US
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Telephone | 925-648-8588
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Fax | 925-648-8008
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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 | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | D6446
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License Number State | AZ
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Taxonomy #2
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | 49186
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License Number State | CA
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