Provider Demographics
NPI:1184246605
Name:PHAM, ANDY
Entity type:Individual
Prefix:MR
First Name:ANDY
Middle Name:
Last Name:PHAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8268 SHANNONS LANDING WAY
Mailing Address - Street 2:
Mailing Address - City:LORTON
Mailing Address - State:VA
Mailing Address - Zip Code:22079-1228
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6926 LITTLE RIVER TPKE STE D
Practice Address - Street 2:
Practice Address - City:ANNANDALE
Practice Address - State:VA
Practice Address - Zip Code:22003-3246
Practice Address - Country:US
Practice Address - Phone:703-354-0181
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-07
Last Update Date:2020-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist