Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223E0200X | Endodontist | 53983 | CA |
NPI | 1003012402 |
---|---|
Provider Name | Dr. Lam Chittaphong |
First Address | San Diego, CA 92126-4579 |
Second Address | San Diego, CA 92126-4579 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 22/06/2007 |
Last Update Date | 01/10/2014 |