MEDICARE: PETER PHAM DDS

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	53936	CA

General Provider Information

NPI Number	:	1114084597
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PETER PHAM DDS

Provider Business Mailing Address
First Line	:	1257 BROCKTON AVE UNIT 101
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90025-7724
Country	:	US
Telephone Number	:	310-486-8500
Fax Number	:

Provider Business Practice Location Address
First Line	:	1257 BROCKTON AVE UNIT 101
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90025-7724
Country	:	US
Telephone Number	:	310-486-8500
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/03/2007
Last Update Date	:	02/03/2009

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