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General NPI Number Information
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NPI Number | 1679912281
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Entity Type | Individual
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Provider Name | JEREMY HUY PHAM DDS
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Gender | Male
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Dates
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Enumeration Date | 06/17/2013
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Last Update Date | 07/24/2013
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Provider Practice Location Address
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Address Line | 22675 ALESSANDRO BLVD
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City | MORENO VALLEY
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State | CA
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Zip | 92553-8551
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Country | US
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Telephone | 951-571-2365
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Fax |
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Provider Business Mailing Address
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Address Line | 821 RANCH VISTA RD
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City | CORONA
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State | CA
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Zip | 92879-7750
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Country | US
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Telephone | 909-217-2676
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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 | 62428
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License Number State | CA
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