Provider Demographics
NPI:1548359359
Name:PHAM, TAM (DDS)
Entity type:Individual
Prefix:DR
First Name:TAM
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 1:8 HILL AVE
Mailing Address - Street 2:
Mailing Address - City:KNIGHTSTOWN
Mailing Address - State:IN
Mailing Address - Zip Code:46148-1228
Mailing Address - Country:US
Mailing Address - Phone:765-345-5677
Mailing Address - Fax:765-345-5617
Practice Address - Street 1:8 HILL AVE
Practice Address - Street 2:
Practice Address - City:KNIGHTSTOWN
Practice Address - State:IN
Practice Address - Zip Code:46148-1228
Practice Address - Country:US
Practice Address - Phone:765-345-5677
Practice Address - Fax:765-345-5617
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2016-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120102261223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200301830AMedicaid