Provider Demographics
NPI:1275787285
Name:LAM, KIET H (DDS)
Entity Type:Individual
Prefix:
First Name:KIET
Middle Name:H
Last Name:LAM
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2472 W FOSTER AVE
Mailing Address - Street 2:STE 101
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625-6962
Mailing Address - Country:US
Mailing Address - Phone:773-334-9922
Mailing Address - Fax:773-334-9928
Practice Address - Street 1:2472 W FOSTER AVE
Practice Address - Street 2:STE 101
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60625-6962
Practice Address - Country:US
Practice Address - Phone:773-334-9922
Practice Address - Fax:773-334-9928
Is Sole Proprietor?:No
Enumeration Date:2008-11-05
Last Update Date:2008-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190251681223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1005225Medicaid