Jacob H. Pham, D.D.S.

Primary specialty

DentistTaxonomy code 122300000X

License

0401413420 Issued in VA

Practice address

6212 Peters Creek Rd
Roanoke, VA 24019-4026

Phone

(540) 563-0519

Fax

(540) 563-1184

NPI assigned

Nov 2, 2005

Last updated

Feb 22, 2016By the provider in NPPES

Sex

Male

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Medicare fee-for-service enrollment

Enrolled in VA

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: No
• Hospice: Yes

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1130889600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1456099200000",
    "number": "1518958248",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "6212 PETERS CREEK RD",
            "city": "ROANOKE",
            "state": "VA",
            "postal_code": "240194026",
            "telephone_number": "540-563-0519",
            "fax_number": "540-563-1184"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "6212 PETERS CREEK RD",
            "city": "ROANOKE",
            "state": "VA",
            "postal_code": "240194026",
            "telephone_number": "540-563-0519",
            "fax_number": "540-563-1184"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "PHAM",
        "first_name": "JACOB",
        "middle_name": "H.",
        "name_prefix": "Dr.",
        "credential": "D.D.S.",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2005-11-02",
        "last_updated": "2016-02-22",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "122300000X",
            "taxonomy_group": "",
            "desc": "Dentist",
            "state": "VA",
            "license": "0401413420",
            "primary": true
        },
        {
            "code": "1223G0001X",
            "taxonomy_group": "",
            "desc": "Dentist, General Practice",
            "state": "VA",
            "license": "0401413420",
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Rebecca Dawn Peterson, COTA/L
• Toni Petrillo, MD
• Theo A Petrocci, LPC
• Jessica Allen Petry
• Kyle D Pfaff, DO
• Long-Quan Duc Pham
• Paula Pham
• Thanh Nga Pham, RPH
• Pharmacy Corporation of America (Express Care Pharmacy)
• Pheasant Ridge Facility Operations, LLC (Pheasant Ridge Nursing & Rehab Center)

• Dentist in Roanoke, VA
• Providers in Roanoke, VA by specialty
• Dentist in Virginia

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 22, 2016; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.