Provider Demographics
NPI:1124648910
Name:WALDON, PHIANH (DMD)
Entity type:Individual
Prefix:
First Name:PHIANH
Middle Name:
Last Name:WALDON
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 1:1801 N PEARL ST APT 2313
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75201-2986
Mailing Address - Country:US
Mailing Address - Phone:608-807-8509
Mailing Address - Fax:
Practice Address - Street 1:3131 TURTLE CREEK BLVD STE 1000
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75219-5439
Practice Address - Country:US
Practice Address - Phone:214-740-4953
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-21
Last Update Date:2023-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIDT-28951223E0200X
TX400351223E0200X
CT12671122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty
No122300000XDental ProvidersDentistGroup - Single Specialty