=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972704740
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LANCE D. HAMILTON, D.D.S., INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/30/2007
-----------------------------------------------------
Last Update Date | 03/11/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 234 E 17TH STREET #107
-----------------------------------------------------
City | COSTA MESA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92627
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-650-6646
-----------------------------------------------------
Fax | 949-650-2451
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 234 E 17TH STREET #107
-----------------------------------------------------
City | COSTA MESA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92627
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-650-6646
-----------------------------------------------------
Fax | 949-650-2451
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/DENTIST
-----------------------------------------------------
Name | DR. LANCE D HAMILTON
-----------------------------------------------------
Credential | D.D.S
-----------------------------------------------------
Telephone | 949-650-6646
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 29712
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------