Provider Demographics
NPI:1154003960
Name:PHEN, VERONICA ALICE (DDS)
Entity type:Individual
Prefix:
First Name:VERONICA
Middle Name:ALICE
Last Name:PHEN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:850 W MARCH LN STE B
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95207-6207
Mailing Address - Country:US
Mailing Address - Phone:209-479-9643
Mailing Address - Fax:
Practice Address - Street 1:2410 SAMPSON ST
Practice Address - Street 2:
Practice Address - City:NORTH CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60088-2942
Practice Address - Country:US
Practice Address - Phone:847-688-2469
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-01
Last Update Date:2023-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT13484084-9921122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist