Provider Demographics
NPI:1316532914
Name:PHAM, JOHNNY DUY
Entity type:Individual
Prefix:
First Name:JOHNNY
Middle Name:DUY
Last Name:PHAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14852 GIVENS PL
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:CA
Mailing Address - Zip Code:92683-5513
Mailing Address - Country:US
Mailing Address - Phone:714-722-8088
Mailing Address - Fax:
Practice Address - Street 1:19720 BEACH BLVD STE A
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92648-2932
Practice Address - Country:US
Practice Address - Phone:714-593-1010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-04
Last Update Date:2022-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADDS1073641223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice