1245827377 NPI number — MARY PHAM DDS DENTAL CORPORATION

Table of content: (NPI 1245827377)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245827377 NPI number — MARY PHAM DDS DENTAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARY PHAM DDS DENTAL CORPORATION
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
LOLLIPOP PEDIATRIC DENTISTRY & ORTHODONTICS
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1245827377
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/03/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2750 HARBOR BLVD STE B6
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COSTA MESA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92626-5121
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
714-528-8252
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13931 CARROLL WAY STE C
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TUSTIN
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92780-1861
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
714-528-8252
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/22/2020

Additional Information

Authorized Official

Authorized Official Last Name:
PHAM
Authorized Official First Name:
MARY
Authorized Official Middle Name:
REGINA
Authorized Official Title or Position:
CEO PEDIATRIC DENTIST
Authorized Official Telephone Number:
714-528-8252

Provider Taxonomy Codes

  • Taxonomy code: 1223P0221X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 1223X0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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