Provider Demographics
NPI:1063485829
Name:LAMB, DEREK H (DMD, MD)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:H
Last Name:LAMB
Suffix:
Gender:M
Credentials:DMD, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3501 N SCOTTSDALE RD STE 226
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85251-5630
Mailing Address - Country:US
Mailing Address - Phone:480-941-5005
Mailing Address - Fax:480-946-0268
Practice Address - Street 1:3501 N SCOTTSDALE RD STE 226
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85251-5630
Practice Address - Country:US
Practice Address - Phone:480-941-5005
Practice Address - Fax:480-946-0268
Is Sole Proprietor?:No
Enumeration Date:2006-02-10
Last Update Date:2013-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN11990204E00000X
MN51977204E00000X
AZ43835204E00000X
AZ078551223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33826700Medicaid
MN832965600Medicaid
MNENROLLEDMedicaid
IAENROLLEDMedicaid
MNP00813445OtherRAILROAD MEDICARE
MNENROLLEDMedicaid
WI33826700Medicaid
MN850000122Medicare PIN