Provider Demographics
NPI:1366917353
Name:PHAM, QUYNH VO BAO (DDS)
Entity type:Individual
Prefix:
First Name:QUYNH
Middle Name:VO BAO
Last Name:PHAM
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10812 PACIFIC CANYON WAY
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92121-4337
Mailing Address - Country:US
Mailing Address - Phone:310-720-5024
Mailing Address - Fax:
Practice Address - Street 1:3767 AVOCADO BLVD
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91941-7301
Practice Address - Country:US
Practice Address - Phone:619-729-2323
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-05
Last Update Date:2018-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADDS1028801223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice