Provider Demographics
NPI:1013479518
Name:PHAM, PAULINE (DDS)
Entity type:Individual
Prefix:
First Name:PAULINE
Middle Name:
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 1:855 W MADISON ST APT 912
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60607-3138
Mailing Address - Country:US
Mailing Address - Phone:408-829-5490
Mailing Address - Fax:
Practice Address - Street 1:801 S PAULINA ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-7210
Practice Address - Country:US
Practice Address - Phone:312-355-1222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-03
Last Update Date:2025-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL018.002298390200000X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL018.002298OtherIDFPR