Provider Demographics
NPI:1124450283
Name:PHANE, PHONG KIM (DMD)
Entity type:Individual
Prefix:DR
First Name:PHONG
Middle Name:KIM
Last Name:PHANE
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 1:3388 49TH ST N
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33710-2146
Mailing Address - Country:US
Mailing Address - Phone:727-323-0377
Mailing Address - Fax:
Practice Address - Street 1:3388 49TH ST N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33710-2146
Practice Address - Country:US
Practice Address - Phone:727-323-0377
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-31
Last Update Date:2014-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN20248122300000X
FLDRP1233122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist