Provider Demographics
NPI:1174675730
Name:LAM, WAN CHI (DDS)
Entity Type:Individual
Prefix:
First Name:WAN
Middle Name:CHI
Last Name:LAM
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 WINCHESTER AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10312-6232
Mailing Address - Country:US
Mailing Address - Phone:718-438-0734
Mailing Address - Fax:718-438-0736
Practice Address - Street 1:824 55TH ST FL 1
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11220-3213
Practice Address - Country:US
Practice Address - Phone:718-438-0734
Practice Address - Fax:718-438-0736
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0480971223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02190843Medicaid