Provider Demographics
NPI:1073174637
Name:PHAN, HUONG THU (DMD)
Entity type:Individual
Prefix:
First Name:HUONG
Middle Name:THU
Last Name:PHAN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4419 FALLBROOK BLVD
Mailing Address - Street 2:
Mailing Address - City:PALM HARBOR
Mailing Address - State:FL
Mailing Address - Zip Code:34685-2653
Mailing Address - Country:US
Mailing Address - Phone:813-420-7005
Mailing Address - Fax:
Practice Address - Street 1:2300 W BROAD ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43204-3783
Practice Address - Country:US
Practice Address - Phone:614-645-2300
Practice Address - Fax:614-645-5517
Is Sole Proprietor?:No
Enumeration Date:2019-06-25
Last Update Date:2025-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPP-000261372122300000X
FLDN255521223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No122300000XDental ProvidersDentist