MEDICARE: DR. THACH PHAM D.M.D

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	DN16419	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1407816903
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. THACH PHAM D.M.D

Provider Business Mailing Address
First Line	:	47 5TH ST NW
Second Line	:
City	:	WINTER HAVEN
State	:	FL
Zip	:	33881-4672
Country	:	US
Telephone Number	:	866-234-8534
Fax Number	:

Provider Business Practice Location Address
First Line	:	1417 LAKELAND HILLS BLVD STE 101
Second Line	:
City	:	LAKELAND
State	:	FL
Zip	:	33805-3200
Country	:	US
Telephone Number	:	866-234-8534
Fax Number	:

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

Provider Enumeration Date	:	03/27/2006
Last Update Date	:	01/05/2022

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