MEDICARE: DR. PHUNG KIM 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	DE00010493	WA
2	1223G0001X	General Practice Dentistry	50508	CA

General Provider Information

NPI Number	:	1265588586
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. PHUNG KIM PHAM DDS

Provider Business Mailing Address
First Line	:	1400 LAKE WASHINGTON BLVD N
Second Line	:	E404
City	:	RENTON
State	:	WA
Zip	:	98056-2564
Country	:	US
Telephone Number	:	425-255-1040
Fax Number	:	425-255-1050

Provider Business Practice Location Address
First Line	:	4700 42ND AVE SW
Second Line	:	SUITE 460
City	:	SEATTLE
State	:	WA
Zip	:	98116-4591
Country	:	US
Telephone Number	:	206-767-4851
Fax Number	:	206-764-0928

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

Provider Enumeration Date	:	01/27/2007
Last Update Date	:	07/08/2007

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