MEDICARE: DR. TRUC T PHAN D.D.S

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	0401411128	VA

General Provider Information

NPI Number	:	1194916254
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TRUC T PHAN D.D.S

Provider Business Mailing Address
First Line	:	42648 BRADFORDS TELEGRAPH CT
Second Line	:
City	:	CHANTILLY
State	:	VA
Zip	:	20152-6323
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4229 LAFAYETTE CENTER DR
Second Line	:	#1225
City	:	CHANTILLY
State	:	VA
Zip	:	20151-1261
Country	:	US
Telephone Number	:	571-214-6485
Fax Number	:

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

Provider Enumeration Date	:	08/05/2007
Last Update Date	:	08/05/2007

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