Provider Demographics
NPI:1922541481
Name:KEITH TAM DDS PROFESSIONAL CORP
Entity Type:Organization
Organization Name:KEITH TAM DDS PROFESSIONAL CORP
Other - Org Name:SANTA MARIA PEDIATRIC DENTAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:
Authorized Official - Last Name:TAM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:949-322-9778
Mailing Address - Street 1:570 E BETTERAVIA RD
Mailing Address - Street 2:STE C
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93454-8805
Mailing Address - Country:US
Mailing Address - Phone:805-922-2888
Mailing Address - Fax:805-925-0888
Practice Address - Street 1:570 E BETTERAVIA RD
Practice Address - Street 2:STE C
Practice Address - City:SANTA MARIA
Practice Address - State:CA
Practice Address - Zip Code:93454-8805
Practice Address - Country:US
Practice Address - Phone:805-922-2888
Practice Address - Fax:805-925-0888
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-30
Last Update Date:2016-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA57293122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty