Provider Demographics
NPI:1235470519
Name:LAU, JENNA Y
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:Y
Last Name:LAU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8882 PROMENADE NORTH PL
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-6456
Mailing Address - Country:US
Mailing Address - Phone:626-258-7027
Mailing Address - Fax:
Practice Address - Street 1:2630 1ST AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-6599
Practice Address - Country:US
Practice Address - Phone:619-234-2158
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-11
Last Update Date:2016-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA637471223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice