Provider Demographics
NPI:1487128518
Name:LAM, JACK (DMD)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:LAM
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:53 ELIZABETH ST FL 2
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10013-4617
Mailing Address - Country:US
Mailing Address - Phone:212-219-8182
Mailing Address - Fax:
Practice Address - Street 1:53 ELIZABETH ST # 2F
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10013-4617
Practice Address - Country:US
Practice Address - Phone:212-219-8182
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-11
Last Update Date:2024-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY060534122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY060534OtherLICENSE