Provider Demographics
NPI:1023291564
Name:LIM, TOM (DDS)
Entity type:Individual
Prefix:
First Name:TOM
Middle Name:
Last Name:LIM
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 1:3901 LAS POSAS ROAD
Mailing Address - Street 2:SUITE 209
Mailing Address - City:CAMARILLO
Mailing Address - State:CA
Mailing Address - Zip Code:93010
Mailing Address - Country:US
Mailing Address - Phone:805-383-6745
Mailing Address - Fax:805-383-2531
Practice Address - Street 1:3901 LAS POSAS ROAD
Practice Address - Street 2:SUITE 209
Practice Address - City:CAMARILLO
Practice Address - State:CA
Practice Address - Zip Code:93010
Practice Address - Country:US
Practice Address - Phone:805-383-6745
Practice Address - Fax:805-383-2531
Is Sole Proprietor?:No
Enumeration Date:2007-12-06
Last Update Date:2007-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA43633122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA523960Medicare UPIN
CAG8983601Medicare PIN