Provider Demographics
NPI:1336372242
Name:PHAN, MINH NGOC (DMD)
Entity type:Individual
Prefix:
First Name:MINH
Middle Name:NGOC
Last Name:PHAN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4660 CORALWOOD CIR
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:CA
Mailing Address - Zip Code:92008-3708
Mailing Address - Country:US
Mailing Address - Phone:971-404-4050
Mailing Address - Fax:
Practice Address - Street 1:4660 CORALWOOD CIR
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:CA
Practice Address - Zip Code:92008-3708
Practice Address - Country:US
Practice Address - Phone:303-469-2061
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-25
Last Update Date:2014-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE601023991223G0001X
CODEN-10341122300000X
CA61348122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist