Provider Demographics
NPI:1720498454
Name:STUDENT IN AN ORGANIZED HEALTH CARE EDUCATION/TRAINING PROGRAM
Entity Type:Organization
Organization Name:STUDENT IN AN ORGANIZED HEALTH CARE EDUCATION/TRAINING PROGRAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RESIDENT DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:
Authorized Official - Last Name:LAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:626-808-6861
Mailing Address - Street 1:940 TIVERTON AVE APT 209
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90024-3036
Mailing Address - Country:US
Mailing Address - Phone:626-808-6861
Mailing Address - Fax:
Practice Address - Street 1:520 N CHANDLER AVE # C
Practice Address - Street 2:
Practice Address - City:MONTEREY PARK
Practice Address - State:CA
Practice Address - Zip Code:91754-1012
Practice Address - Country:US
Practice Address - Phone:626-808-6861
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-02
Last Update Date:2014-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty