Provider Demographics
NPI:1679627665
Name:PHUNG, KIM KHUE THI (DDS)
Entity type:Individual
Prefix:
First Name:KIM KHUE
Middle Name:THI
Last Name:PHUNG
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 E 10TH ST
Mailing Address - Street 2:#K
Mailing Address - City:GILROY
Mailing Address - State:CA
Mailing Address - Zip Code:95020-6580
Mailing Address - Country:US
Mailing Address - Phone:408-842-9439
Mailing Address - Fax:408-842-9475
Practice Address - Street 1:220 E 10TH ST
Practice Address - Street 2:#K
Practice Address - City:GILROY
Practice Address - State:CA
Practice Address - Zip Code:95020-6580
Practice Address - Country:US
Practice Address - Phone:408-842-9439
Practice Address - Fax:408-842-9475
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA457561223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice