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General NPI Number Information
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NPI Number | 1609181858
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Entity Type | Organization
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Legal Business Name | KTAM DDS DENTAL CORP
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Dates
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Enumeration Date | 08/12/2010
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Last Update Date | 10/08/2010
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Provider Practice Location Address
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Address Line | 1505 SHEPARD DR #201
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City | SANTA MARIA
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State | CA
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Zip | 93454-7020
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Country | US
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Telephone | 949-322-9778
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Fax |
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Provider Business Mailing Address
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Address Line | 1505 SHEPARD DR #201
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City | SANTA MARIA
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State | CA
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Zip | 93454-7020
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Country | US
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Telephone | 949-322-9778
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | KEITH TAM
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Credential | DDS
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Telephone | 949-322-9778
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number | 57293
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License Number State | CA
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