Provider Demographics
NPI:1538165576
Name:LAI, KHIEM DINH (MD)
Entity type:Individual
Prefix:DR
First Name:KHIEM
Middle Name:DINH
Last Name:LAI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4418 OAKFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92703-1636
Mailing Address - Country:US
Mailing Address - Phone:714-721-7116
Mailing Address - Fax:
Practice Address - Street 1:12502 BROOKHURST ST
Practice Address - Street 2:
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92840-4807
Practice Address - Country:US
Practice Address - Phone:714-537-0547
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-23
Last Update Date:2009-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA86360207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A863600Medicaid
CA00A863600Medicaid
CAA86360Medicare PIN