Provider Demographics
NPI:1144363326
Name:PHAN, HAI THANH (DDS)
Entity type:Individual
Prefix:DR
First Name:HAI
Middle Name:THANH
Last Name:PHAN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:492 N 13TH ST
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95112-1719
Mailing Address - Country:US
Mailing Address - Phone:408-286-2326
Mailing Address - Fax:
Practice Address - Street 1:1672 MCKEE RD
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95116-1235
Practice Address - Country:US
Practice Address - Phone:408-272-3999
Practice Address - Fax:408-272-2202
Is Sole Proprietor?:No
Enumeration Date:2007-02-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA466711223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAD46671Medicaid