Provider Demographics
NPI:1114158896
Name:LAU, JERRY (DDS)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:
Last Name:LAU
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8201 EDGEWATER DR
Mailing Address - Street 2:SUITE 106
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94621-2016
Mailing Address - Country:US
Mailing Address - Phone:510-568-3577
Mailing Address - Fax:
Practice Address - Street 1:8201 EDGEWATER DR
Practice Address - Street 2:SUITE 106
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94621-2016
Practice Address - Country:US
Practice Address - Phone:510-568-3577
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-29
Last Update Date:2009-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA584811223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice