Healthcare Provider Details

I. General information

NPI: 1467304188
Provider Name (Legal Business Name): SAN GABRIEL VALLEY ORAL & FACIAL SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/13/2026
Last Update Date: 02/13/2026
Certification Date: 02/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

126 S GLENDORA AVE STE 108
WEST COVINA CA
91790-3047
US

IV. Provider business mailing address

126 S GLENDORA AVE STE 108
WEST COVINA CA
91790-3047
US

V. Phone/Fax

Practice location:
  • Phone: 626-966-8518
  • Fax: 626-967-0990
Mailing address:
  • Phone: 626-966-8518
  • Fax: 626-967-0990

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS0112X
TaxonomyOral and Maxillofacial Surgery Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. PETER LAM
Title or Position: PARTNER/ORAL SURGEON
Credential: DDS
Phone: 626-966-8518