Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 122300000X | Dentist | 55416 | CA |
Y | 1223P0700X | Prosthodontist | 55416 | CA |
NPI | 1235367509 |
---|---|
Provider Name | Dr. Jung Nam |
First Address | Palo Alto, CA 94306-1054 |
Second Address | Palo Alto, CA 94306-1054 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 25/06/2009 |
Last Update Date | 17/03/2020 |