Provider Demographics
NPI:1043044613
Name:PHAN, KATHLEEN P (DMD)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:P
Last Name:PHAN
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 1:634 TRUE WIND WAY UNIT 803
Mailing Address - Street 2:
Mailing Address - City:REDWOOD CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94063-5733
Mailing Address - Country:US
Mailing Address - Phone:408-250-1375
Mailing Address - Fax:
Practice Address - Street 1:14501 S BASCOM AVE STE G
Practice Address - Street 2:
Practice Address - City:LOS GATOS
Practice Address - State:CA
Practice Address - Zip Code:95032-2003
Practice Address - Country:US
Practice Address - Phone:408-214-6752
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-27
Last Update Date:2024-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA110051122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist