MEDICARE: PHUONG THUY LE PHAM 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	122300000X	Dentist	D14286	MN

General Provider Information

NPI Number	:	1740841428
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PHUONG THUY LE PHAM DDS

Provider Business Mailing Address
First Line	:	2568 43RD AVE S
Second Line	:
City	:	SAINT CLOUD
State	:	MN
Zip	:	56301-5493
Country	:	US
Telephone Number	:	320-267-9332
Fax Number	:

Provider Business Practice Location Address
First Line	:	2305 MINNESOTA BLVD
Second Line	:
City	:	SAINT CLOUD
State	:	MN
Zip	:	56304-2424
Country	:	US
Telephone Number	:	320-240-6781
Fax Number	:

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

Provider Enumeration Date	:	06/24/2019
Last Update Date	:	07/11/2022

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