MEDICARE: LOC B PHAM DDS & TRACY T NGUYEN DDS PROFESSIONAL CORP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	46508	CA
2	1223G0001X	General Practice Dentistry	46515	CA

General Provider Information

NPI Number	:	1104911940
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LOC B PHAM DDS & TRACY T NGUYEN DDS PROFESSIONAL CORP

Provider Business Mailing Address
First Line	:	2344 MCKEE ROAD
Second Line	:	SUITE 50
City	:	SAN JOSE
State	:	CA
Zip	:	95116-1616
Country	:	US
Telephone Number	:	408-251-0118
Fax Number	:	408-251-0119

Provider Business Practice Location Address
First Line	:	2344 MCKEE ROAD
Second Line	:	SUITE 50
City	:	SAN JOSE
State	:	CA
Zip	:	95116-1616
Country	:	US
Telephone Number	:	408-251-0118
Fax Number	:	408-251-0119

Authorized Official
Title or Position	:	DENTIST SECER SECRETARY
Name	:	MR. LOC B PHAM
Credential	:	DDS
Telephone Number	:	408-251-0118

Provider Enumeration Date	:	10/04/2006
Last Update Date	:	08/22/2020

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