Provider Demographics
NPI:1285314252
Name:PHAN, JOLEEN THI (DMD)
Entity type:Individual
Prefix:DR
First Name:JOLEEN
Middle Name:THI
Last Name:PHAN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:DR
Other - First Name:JOLEEN
Other - Middle Name:THI
Other - Last Name:PHAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMD
Mailing Address - Street 1:3101 HOUMA HIGHLANDS CT
Mailing Address - Street 2:
Mailing Address - City:HOUMA
Mailing Address - State:LA
Mailing Address - Zip Code:70360-6909
Mailing Address - Country:US
Mailing Address - Phone:504-635-5125
Mailing Address - Fax:
Practice Address - Street 1:14243 US-90
Practice Address - Street 2:
Practice Address - City:BOUTTE
Practice Address - State:LA
Practice Address - Zip Code:70039
Practice Address - Country:US
Practice Address - Phone:985-758-5110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-24
Last Update Date:2023-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA7479122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist