Provider Demographics
NPI:1164267282
Name:PHAN, THAO THI THU (DDS)
Entity type:Individual
Prefix:
First Name:THAO
Middle Name:THI THU
Last Name:PHAN
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 1:9647 WOODLAND BROOK LN S
Mailing Address - Street 2:
Mailing Address - City:CORDOVA
Mailing Address - State:TN
Mailing Address - Zip Code:38018-3648
Mailing Address - Country:US
Mailing Address - Phone:931-261-7166
Mailing Address - Fax:
Practice Address - Street 1:508 N CHURCH ST # 100
Practice Address - Street 2:
Practice Address - City:LIVINGSTON
Practice Address - State:TN
Practice Address - Zip Code:38570-1539
Practice Address - Country:US
Practice Address - Phone:931-823-3754
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-29
Last Update Date:2024-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN125431223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice