MEDICARE: DR. KHIEM B PHAM-NGUYEN 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	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	20940	MA

General Provider Information

NPI Number	:	1720249501
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KHIEM B PHAM-NGUYEN DMD

Provider Business Mailing Address
First Line	:	35 NORTHAMPTON ST APT 2110
Second Line	:
City	:	BOSTON
State	:	MA
Zip	:	02118-4020
Country	:	US
Telephone Number	:	617-817-4577
Fax Number	:

Provider Business Practice Location Address
First Line	:	15 FRONT ST
Second Line	:
City	:	WEYMOUTH
State	:	MA
Zip	:	02188-1604
Country	:	US
Telephone Number	:	617-817-4577
Fax Number	:

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

Provider Enumeration Date	:	06/24/2008
Last Update Date	:	06/24/2008

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