Active NPI
Jackline Anh-Dao Pham, DDS
- General Practice Dentistry
- San Diego, CA
National Provider Identifier
1992835235
On this page
Key facts
NPPES NPI Registry- Primary specialty
- General Practice Dentistry
- License
- 45309
- Practice address
- 4344 Convoy Street
Suite S
San Diego, CA 92111 - Phone
- (858) 616-6468
- Fax
- (858) 616-6478
- NPI assigned
- Mar 6, 2007
- Sex
- Female
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| General Practice Dentistry | 1223G0001X | 45309 | CA | Primary |
Addresses
Primary practice location
4344 Convoy Street
Suite S
San Diego, CA 92111
Mailing address
4344 Convoy Street
Suite S
San Diego, CA 92111
Phone (858) 616-6468
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in CA
- Eligible to order & refer
- Part B services: Yes
- Medical equipment: Yes
- Home health: Yes
- Power mobility devices: No
- Hospice: Yes
Enrollment records 1
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20160906002251 | CA | Order and Referring Only - Dentist | 5395031074 |
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 45309 | CA | MD | Marriage & Family Therapist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1173139200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1614038400000",
"number": "1992835235",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "4344 CONVOY STREET",
"address_2": "SUITE S",
"city": "SAN DIEGO",
"state": "CA",
"postal_code": "92111",
"telephone_number": "858-616-6468",
"fax_number": "858-616-6478"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "4344 CONVOY STREET",
"address_2": "SUITE S",
"city": "SAN DIEGO",
"state": "CA",
"postal_code": "92111",
"telephone_number": "858-616-6468",
"fax_number": "858-616-6478"
}
],
"practiceLocations": [],
"basic": {
"last_name": "PHAM",
"first_name": "JACKLINE",
"middle_name": "ANH-DAO",
"name_prefix": "Dr.",
"credential": "DDS",
"sole_proprietor": "YES",
"sex": "F",
"enumeration_date": "2007-03-06",
"last_updated": "2021-02-23",
"certification_date": "2021-02-23",
"status": "A"
},
"taxonomies": [
{
"code": "1223G0001X",
"taxonomy_group": "",
"desc": "Dentist, General Practice",
"state": "CA",
"license": "45309",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in San Diego, CA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 23, 2021; 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.