Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 126800000X | Dental Assistant | 75326 | CA |
NPI | 1144633959 |
---|---|
Provider Name | Hong Phan |
First Address | San Pablo, CA 94806-3227 |
Second Address | Oakland, CA 94601-2228 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 09/06/2014 |
Last Update Date | 09/06/2014 |