Provider Demographics
NPI:1154113538
Name:PHAN, ANHTUAN VAN (LD)
Entity type:Individual
Prefix:
First Name:ANHTUAN
Middle Name:VAN
Last Name:PHAN
Suffix:
Gender:M
Credentials:LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9518 MCKINLEY AVE
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98445-2168
Mailing Address - Country:US
Mailing Address - Phone:253-617-5704
Mailing Address - Fax:
Practice Address - Street 1:7808 PACIFIC AVE STE 6
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98408-7039
Practice Address - Country:US
Practice Address - Phone:253-617-5704
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-21
Last Update Date:2025-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61521236122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122400000XDental ProvidersDenturist