Provider Demographics
NPI:1063670776
Name:LAM, JACK (DMD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:
Last Name:LAM
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 S PARK VICTORIA DR
Mailing Address - Street 2:
Mailing Address - City:MILPITAS
Mailing Address - State:CA
Mailing Address - Zip Code:95035-5720
Mailing Address - Country:US
Mailing Address - Phone:408-942-1000
Mailing Address - Fax:
Practice Address - Street 1:33 S PARK VICTORIA DR
Practice Address - Street 2:
Practice Address - City:MILPITAS
Practice Address - State:CA
Practice Address - Zip Code:95035-5720
Practice Address - Country:US
Practice Address - Phone:408-942-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-29
Last Update Date:2008-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA357501223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice