Provider Demographics
NPI:1396274569
Name:LAM, VIDA WING LONG (DDS)
Entity type:Individual
Prefix:
First Name:VIDA WING LONG
Middle Name:
Last Name:LAM
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:475 SEAVIEW AVENUE
Mailing Address - Street 2:DEPARTMENT OF DENTISTRY
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:475 SEAVIEW AVENUE
Practice Address - Street 2:DEPARTMENT OF DENTISTRY
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10305
Practice Address - Country:US
Practice Address - Phone:718-226-9080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-09
Last Update Date:2018-01-24
Deactivation Date:2018-01-11
Deactivation Code:
Reactivation Date:2018-01-24
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program