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General NPI Number Information
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NPI Number | 1619460193
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Entity Type | Individual
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Provider Name | TIFFANY LAN PHAM
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Gender | Female
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Dates
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Enumeration Date | 06/11/2018
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Last Update Date | 06/11/2018
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Provider Practice Location Address
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Address Line | 967 N GARDEN RIDGE BLVD
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City | LEWISVILLE
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State | TX
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Zip | 75077-2800
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Country | US
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Telephone | 972-537-5730
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Fax |
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Provider Business Mailing Address
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Address Line | 2419 BENNINGTON DR
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City | ARLINGTON
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State | TX
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Zip | 76018-1915
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Country | US
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Telephone |
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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 | 122300000X
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Taxonomy Name | Dentist
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License Number | 34115
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License Number State | TX
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