=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659825255
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SEAN BRIAN HAM DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/11/2016
-----------------------------------------------------
Last Update Date | 11/20/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9750 N ORACLE RD APT 17105
-----------------------------------------------------
City | ORO VALLEY
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85704-7689
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-404-9425
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9750 N ORACLE RD APT 17105
-----------------------------------------------------
City | ORO VALLEY
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85704-7689
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-404-9425
-----------------------------------------------------
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 | DDS100574
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 10567
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------