MEDICARE: DR. MICHAEL T PHAM DMD

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	4769	NV

General Provider Information

NPI Number	:	1619154507
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MICHAEL T PHAM DMD

Provider Business Mailing Address
First Line	:	5905 S EASTERN AVE STE 112
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89119-3130
Country	:	US
Telephone Number	:	702-262-5693
Fax Number	:	702-262-1301

Provider Business Practice Location Address
First Line	:	5905 S EASTERN AVE STE 112
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89119-3130
Country	:	US
Telephone Number	:	702-262-5693
Fax Number	:	702-262-5693

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

Provider Enumeration Date	:	01/23/2008
Last Update Date	:	06/08/2015

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