=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659104636
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NATHAN TAM
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/23/2024
-----------------------------------------------------
Last Update Date | 02/11/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 27081 185TH AVE SE
-----------------------------------------------------
City | COVINGTON
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98042-8448
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-257-6882
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1250 N ABBEY LN UNIT 251
-----------------------------------------------------
City | CHANDLER
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85226-1555
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-257-6882
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | DE61689979
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------