Provider Demographics
NPI:1225204795
Name:LAI, TRACEY-PHUONG TO (DMD)
Entity Type:Individual
Prefix:DR
First Name:TRACEY-PHUONG
Middle Name:TO
Last Name:LAI
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:288 COMMON ST
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02472-4940
Mailing Address - Country:US
Mailing Address - Phone:626-759-2770
Mailing Address - Fax:
Practice Address - Street 1:288 COMMON ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:MA
Practice Address - Zip Code:02472-4940
Practice Address - Country:US
Practice Address - Phone:626-759-2770
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-05
Last Update Date:2012-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA56463122300000X
MA21400122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist