Provider Demographics
NPI:1225209828
Name:CHARLENE LAU DDS PLLC
Entity Type:Organization
Organization Name:CHARLENE LAU DDS PLLC
Other - Org Name:JACKSON HEIGHTS FAMILY DENTAL
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLENE
Authorized Official - Middle Name:S
Authorized Official - Last Name:LAU
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:718-898-0300
Mailing Address - Street 1:35-60 74TH STREET
Mailing Address - Street 2:#103
Mailing Address - City:JACKSON HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:11372-4316
Mailing Address - Country:US
Mailing Address - Phone:718-898-0300
Mailing Address - Fax:718-478-1123
Practice Address - Street 1:35-60 74TH STREET
Practice Address - Street 2:#103
Practice Address - City:JACKSON HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:11372-4316
Practice Address - Country:US
Practice Address - Phone:718-898-0300
Practice Address - Fax:718-478-1123
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-22
Last Update Date:2009-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0456271223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01607478Medicaid