Provider Demographics
NPI:1194916254
Name:PHAN, TRUC T (DDS)
Entity type:Individual
Prefix:DR
First Name:TRUC
Middle Name:T
Last Name:PHAN
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 1:42648 BRADFORDS TELEGRAPH CT
Mailing Address - Street 2:
Mailing Address - City:CHANTILLY
Mailing Address - State:VA
Mailing Address - Zip Code:20152-6323
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4229 LAFAYETTE CENTER DR
Practice Address - Street 2:#1225
Practice Address - City:CHANTILLY
Practice Address - State:VA
Practice Address - Zip Code:20151-1261
Practice Address - Country:US
Practice Address - Phone:571-214-6485
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-05
Last Update Date:2007-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014111281223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice