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General NPI Number Information
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NPI Number | 1740012202
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Entity Type | Individual
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Provider Name | KEVIN PHAN DDS
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Gender | Male
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Dates
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Enumeration Date | 08/14/2024
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Last Update Date | 11/13/2024
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Provider Practice Location Address
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Address Line | 2855 LAWRENCEVILLE SUWANEE RD STE 360
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City | SUWANEE
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State | GA
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Zip | 30024-3596
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Country | US
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Telephone | 678-482-2197
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Fax |
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Provider Business Mailing Address
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Address Line | 410 TAMBEC TRCE NW
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City | LILBURN
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State | GA
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Zip | 30047-2860
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Country | US
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Telephone | 404-663-3146
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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 | DN123575
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License Number State | GA
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