Provider Demographics
NPI:1538427745
Name:MARK PHAM, DMD, PC
Entity type:Organization
Organization Name:MARK PHAM, DMD, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:PHAM
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:617-820-6447
Mailing Address - Street 1:57 OBERY ST
Mailing Address - Street 2:SUITE 2
Mailing Address - City:PLYMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02360
Mailing Address - Country:US
Mailing Address - Phone:617-820-6447
Mailing Address - Fax:
Practice Address - Street 1:57 OBERY ST
Practice Address - Street 2:SUITE 2
Practice Address - City:PLYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02360-2480
Practice Address - Country:US
Practice Address - Phone:617-820-6447
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-25
Last Update Date:2012-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN210731223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty