=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831413350
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LAM DENTAL CORP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/26/2010
-----------------------------------------------------
Last Update Date | 03/26/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10165 FOOTHILL BLVD SUITE # 4, 5
-----------------------------------------------------
City | RANCHO CUCAMONGA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91730-0340
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-458-2516
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10165 FOOTHILL BLVD SUITE # 4, 5
-----------------------------------------------------
City | RANCHO CUCAMONGA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91730-0340
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-458-2516
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. THAI TOM LAM
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 818-458-2516
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number | 54770
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------