Provider Demographics
NPI:1396172235
Name:PHUNG, NICHOLAS (DMD)
Entity type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:
Last Name:PHUNG
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1055 PAPER CREEK DR
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30046-5358
Mailing Address - Country:US
Mailing Address - Phone:404-932-4705
Mailing Address - Fax:
Practice Address - Street 1:1450 SR 138
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30013
Practice Address - Country:US
Practice Address - Phone:404-932-4705
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-10-10
Last Update Date:2013-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN014688122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist