MEDICARE: DR. THOI PHU PHAN 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	32222	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	32222	OTHER	CA	CA LIC

General Provider Information

NPI Number	:	1285601211
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. THOI PHU PHAN DDS

Provider Business Mailing Address
First Line	:	1692 TULLY RD
Second Line	:	STE 4
City	:	SAN JOSE
State	:	CA
Zip	:	95122-2549
Country	:	US
Telephone Number	:	206-203-0588
Fax Number	:

Provider Business Practice Location Address
First Line	:	1692 TULLY RD
Second Line	:	STE 4
City	:	SAN JOSE
State	:	CA
Zip	:	95122-2549
Country	:	US
Telephone Number	:	206-203-0588
Fax Number	:

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

Provider Enumeration Date	:	03/08/2006
Last Update Date	:	08/16/2007

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