Provider Demographics
NPI:1184731598
Name:PHAM, NHUNG (DMD)
Entity type:Individual
Prefix:
First Name:NHUNG
Middle Name:
Last Name:PHAM
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:449 E ELM ST
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85705-6713
Mailing Address - Country:US
Mailing Address - Phone:520-850-9512
Mailing Address - Fax:520-622-6322
Practice Address - Street 1:4001 E BROADWAY BLVD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85711-3454
Practice Address - Country:US
Practice Address - Phone:520-850-9512
Practice Address - Fax:520-622-6322
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA21503122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0205214Medicaid