MEDICARE: THI THI CONG 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	49393	CA

General Provider Information

NPI Number	:	1548780604
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	THI THI CONG PHAN DDS

Provider Business Mailing Address
First Line	:	619 LANCASHIRE PL
Second Line	:
City	:	SAN MARCOS
State	:	CA
Zip	:	92069-8108
Country	:	US
Telephone Number	:	760-807-3669
Fax Number	:

Provider Business Practice Location Address
First Line	:	2630 EL CAMINO REAL
Second Line	:
City	:	CARLSBAD
State	:	CA
Zip	:	92008-1214
Country	:	US
Telephone Number	:	760-434-1761
Fax Number	:

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

Provider Enumeration Date	:	06/21/2017
Last Update Date	:	06/21/2017

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