MEDICARE: DR. PHONG KIM PHANE DMD

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	122300000X	Dentist	DN20248	FL
2	122300000X	Dentist	DRP1233	FL

General Provider Information

NPI Number	:	1124450283
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. PHONG KIM PHANE DMD

Provider Business Mailing Address
First Line	:	3388 49TH ST N
Second Line	:
City	:	ST PETERSBURG
State	:	FL
Zip	:	33710-2146
Country	:	US
Telephone Number	:	727-323-0377
Fax Number	:

Provider Business Practice Location Address
First Line	:	3388 49TH ST N
Second Line	:
City	:	ST PETERSBURG
State	:	FL
Zip	:	33710-2146
Country	:	US
Telephone Number	:	727-323-0377
Fax Number	:

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

Provider Enumeration Date	:	07/31/2013
Last Update Date	:	10/20/2014

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