Provider Demographics
NPI:1528275021
Name:PHAM, KIM THU (DMD)
Entity type:Individual
Prefix:DR
First Name:KIM
Middle Name:THU
Last Name:PHAM
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 1:2690 PACIFIC AVE
Mailing Address - Street 2:SUITE #360
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90806-2657
Mailing Address - Country:US
Mailing Address - Phone:562-290-0420
Mailing Address - Fax:562-290-0428
Practice Address - Street 1:2690 PACIFIC AVE
Practice Address - Street 2:SUITE #360
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90806-2657
Practice Address - Country:US
Practice Address - Phone:562-290-0420
Practice Address - Fax:562-290-0428
Is Sole Proprietor?:No
Enumeration Date:2007-05-16
Last Update Date:2017-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA555001223G0001X
NY0515161223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02624766Medicaid