Provider Demographics
NPI:1366109357
Name:MATT T PHAN DMD PC
Entity type:Organization
Organization Name:MATT T PHAN DMD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MATT
Authorized Official - Middle Name:
Authorized Official - Last Name:PHAN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:949-440-1105
Mailing Address - Street 1:13882 NEWPORT AVE STE B
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-4666
Mailing Address - Country:US
Mailing Address - Phone:949-440-1105
Mailing Address - Fax:949-440-1107
Practice Address - Street 1:13882 NEWPORT AVE STE B
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-4666
Practice Address - Country:US
Practice Address - Phone:949-440-1105
Practice Address - Fax:949-440-1107
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-24
Last Update Date:2021-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental