Provider Demographics
NPI:1487870457
Name:PHAM, PHUNG KIM (DDS)
Entity type:Individual
Prefix:DR
First Name:PHUNG
Middle Name:KIM
Last Name:PHAM
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1727 N FRESNO ST
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93703-3031
Mailing Address - Country:US
Mailing Address - Phone:559-227-5239
Mailing Address - Fax:559-227-9262
Practice Address - Street 1:1727 N FRESNO ST
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93703-3031
Practice Address - Country:US
Practice Address - Phone:559-227-5239
Practice Address - Fax:559-227-9262
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2017-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA524531223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAD52453OtherRENDERING PROVIDER NUMBER