Provider Demographics
NPI:1548629694
Name:THE T. PHAN, DDS, MD PROFESSIONAL CORP
Entity type:Organization
Organization Name:THE T. PHAN, DDS, MD PROFESSIONAL CORP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:BRITTANY
Authorized Official - Middle Name:
Authorized Official - Last Name:WHARTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:805-600-4540
Mailing Address - Street 1:1620 NEWBURY RD STE 5
Mailing Address - Street 2:
Mailing Address - City:NEWBURY PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91320-3401
Mailing Address - Country:US
Mailing Address - Phone:805-600-4540
Mailing Address - Fax:805-456-0768
Practice Address - Street 1:1620 NEWBURY RD STE 5
Practice Address - Street 2:
Practice Address - City:NEWBURY PARK
Practice Address - State:CA
Practice Address - Zip Code:91320-3401
Practice Address - Country:US
Practice Address - Phone:805-600-4540
Practice Address - Fax:805-456-0768
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-17
Last Update Date:2016-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA554271223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty