MEDICARE: WAN CHI LAM D.D.S

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	048097	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1174675730
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WAN CHI LAM D.D.S

Provider Business Mailing Address
First Line	:	116 WINCHESTER AVE
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10312-6232
Country	:	US
Telephone Number	:	718-438-0734
Fax Number	:	718-438-0736

Provider Business Practice Location Address
First Line	:	824 55TH ST FL 1
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11220-3213
Country	:	US
Telephone Number	:	718-438-0734
Fax Number	:	718-438-0736

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/16/2007
Last Update Date	:	07/08/2007

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