MEDICARE: MICHAEL TUNG PHAM, DMD, PC

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	4769	NV

General Provider Information

NPI Number	:	1871822486
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MICHAEL TUNG PHAM, DMD, PC

Provider Business Mailing Address
First Line	:	5905 S EASTERN AVE
Second Line	:	SUITE 112
City	:	LAS VEGAS
State	:	NV
Zip	:	89119-3129
Country	:	US
Telephone Number	:	702-262-5693
Fax Number	:

Provider Business Practice Location Address
First Line	:	5905 S EASTERN AVE
Second Line	:	SUITE 112
City	:	LAS VEGAS
State	:	NV
Zip	:	89119-3129
Country	:	US
Telephone Number	:	702-262-5693
Fax Number	:

Authorized Official
Title or Position	:	DENTIST/PRESIDENT/OWNER
Name	:	DR. MICHAEL TUNG PHAM
Credential	:	DMD
Telephone Number	:	702-262-5693

Provider Enumeration Date	:	12/10/2009
Last Update Date	:	12/10/2009

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