Healthcare Provider Details

I. General information

NPI: 1962321836
Provider Name (Legal Business Name): ANDREW NGUYEN LAM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/14/2026
Last Update Date: 07/14/2026
Certification Date: 07/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

851 PARK DR STE 101
LAKE GENEVA WI
53147-4586
US

IV. Provider business mailing address

9501 OZANAM AVE
MORTON GROVE IL
60053-1060
US

V. Phone/Fax

Practice location:
  • Phone: 262-248-4991
  • Fax:
Mailing address:
  • Phone: 847-834-5360
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number600229015
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: