Provider Demographics
NPI:1285942441
Name:PHAN, THU THAO
Entity type:Individual
Prefix:
First Name:THU THAO
Middle Name:
Last Name:PHAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14942 JACKSON ST # C3
Mailing Address - Street 2:
Mailing Address - City:MIDWAY CITY
Mailing Address - State:CA
Mailing Address - Zip Code:92655-1230
Mailing Address - Country:US
Mailing Address - Phone:714-200-5325
Mailing Address - Fax:
Practice Address - Street 1:767 N HILL ST STE 200
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90012-2365
Practice Address - Country:US
Practice Address - Phone:714-200-5325
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-21
Last Update Date:2010-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA59521122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist