Provider Demographics
NPI:1679086243
Name:SAN GABRIEL VALLEY ORAL AND FACIAL SURGERY
Entity Type:Organization
Organization Name:SAN GABRIEL VALLEY ORAL AND FACIAL SURGERY
Other - Org Name:PETER S. LAM DDS, INC.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:PATTY
Authorized Official - Middle Name:K
Authorized Official - Last Name:BOGLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:626-966-8518
Mailing Address - Street 1:126 S GLENDORA AVE STE 108
Mailing Address - Street 2:
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91790-3047
Mailing Address - Country:US
Mailing Address - Phone:626-966-8518
Mailing Address - Fax:626-967-0990
Practice Address - Street 1:126 S GLENDORA AVE STE 108
Practice Address - Street 2:
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91790-3047
Practice Address - Country:US
Practice Address - Phone:626-966-8518
Practice Address - Fax:626-967-0990
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-06
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA40257261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental