=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609218528
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | STEVEN TAM, DMD, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/19/2013
-----------------------------------------------------
Last Update Date | 07/19/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4225 80TH ST UNIT LA
-----------------------------------------------------
City | ELMHURST
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11373-3070
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-592-1885
-----------------------------------------------------
Fax | 718-592-2034
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4225 80TH ST UNIT LA
-----------------------------------------------------
City | ELMHURST
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11373-3070
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-592-1885
-----------------------------------------------------
Fax | 718-592-2034
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. STEVEN TAM
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 718-592-1885
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 042748
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------