Provider Demographics
NPI:1215164652
Name:PHAN, UYEN T (RDH)
Entity type:Individual
Prefix:
First Name:UYEN
Middle Name:T
Last Name:PHAN
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1927 FAITHON P LUCAS SR BLVD # SR
Mailing Address - Street 2:SUITE120
Mailing Address - City:MESQUITE
Mailing Address - State:TX
Mailing Address - Zip Code:75181-1696
Mailing Address - Country:US
Mailing Address - Phone:469-341-3888
Mailing Address - Fax:
Practice Address - Street 1:1927 FAITHON P LUCAS SR BLVD # SR
Practice Address - Street 2:SUITE120
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75181-1696
Practice Address - Country:US
Practice Address - Phone:469-341-3888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-11
Last Update Date:2009-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX14848124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX14848OtherDENTAL