Provider Demographics
NPI:1508864695
Name:NAM, IL WOO (DDS)
Entity Type:Individual
Prefix:MR
First Name:IL
Middle Name:WOO
Last Name:NAM
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 1:17675 VAN BUREN BLVD
Mailing Address - Street 2:SUITE D
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92504-6076
Mailing Address - Country:US
Mailing Address - Phone:951-789-1133
Mailing Address - Fax:951-789-2560
Practice Address - Street 1:17675 VAN BUREN BLVD
Practice Address - Street 2:SUITE D
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92504-6076
Practice Address - Country:US
Practice Address - Phone:951-789-1133
Practice Address - Fax:951-789-2560
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA32978122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist