Healthcare Provider Details

I. General information

NPI: 1104166107
Provider Name (Legal Business Name): JENNIFER LAM RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/27/2013
Last Update Date: 02/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15350 NORDHOFF ST
NORTH HILLS CA
91343-2234
US

IV. Provider business mailing address

3053 BIANCA CIR
SIMI VALLEY CA
93063-1521
US

V. Phone/Fax

Practice location:
  • Phone: 818-672-8228
  • Fax:
Mailing address:
  • Phone: 805-584-2719
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number26585
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: