Provider Demographics
NPI:1861525818
Name:PHAM, GINA CUC (DDS)
Entity type:Individual
Prefix:DR
First Name:GINA
Middle Name:CUC
Last Name:PHAM
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:GINA
Other - Middle Name:CUC
Other - Last Name:PHAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:PO BOX 10083
Mailing Address - Street 2:
Mailing Address - City:MC LEAN
Mailing Address - State:VA
Mailing Address - Zip Code:22102-8083
Mailing Address - Country:US
Mailing Address - Phone:703-626-8196
Mailing Address - Fax:
Practice Address - Street 1:12602 LAKE RIDGE DR
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192-2335
Practice Address - Country:US
Practice Address - Phone:703-490-5050
Practice Address - Fax:703-490-1155
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-13
Last Update Date:2021-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD13454122300000X
DCDEN10014331223P0221X
VA04014117751223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No122300000XDental ProvidersDentist