Provider Demographics
NPI:1497009831
Name:KEITH H TAM DDS INC
Entity Type:Organization
Organization Name:KEITH H TAM DDS INC
Other - Org Name:LAKE FOREST PEDIATRIC DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER, DDS
Authorized Official - Prefix:DR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:H
Authorized Official - Last Name:TAM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:949-322-9778
Mailing Address - Street 1:2674 SAN MIGUEL DR STE C
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-5437
Mailing Address - Country:US
Mailing Address - Phone:949-478-6628
Mailing Address - Fax:
Practice Address - Street 1:2674 SAN MIGUEL DR
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-5437
Practice Address - Country:US
Practice Address - Phone:949-478-6628
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KEITH TAM DDS PROFESSIONAL CORP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-11-07
Last Update Date:2022-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA572931223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty