MEDICARE: THI PHAN DENTAL 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	261QD0000X	Dental Clinic/Center	40484	CA

General Provider Information

NPI Number	:	1144656406
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THI PHAN DENTAL CORP

Provider Business Mailing Address
First Line	:	1540 FERN ST
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92102-1536
Country	:	US
Telephone Number	:	619-236-9549
Fax Number	:	619-234-0311

Provider Business Practice Location Address
First Line	:	1540 FERN ST
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92102-1536
Country	:	US
Telephone Number	:	619-236-9549
Fax Number	:	619-234-0311

Authorized Official
Title or Position	:	PRESIDENT/OWNER
Name	:	THI BINH PHAN
Credential	:	DDS
Telephone Number	:	619-236-9549

Provider Enumeration Date	:	09/18/2013
Last Update Date	:	09/18/2013

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