Provider Demographics
NPI:1710930573
Name:LAW, ALAN S (DDS, PHD)
Entity Type:Individual
Prefix:
First Name:ALAN
Middle Name:S
Last Name:LAW
Suffix:
Gender:M
Credentials:DDS, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 OTTER LAKE DR
Mailing Address - Street 2:
Mailing Address - City:WHITE BEAR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55110-1064
Mailing Address - Country:US
Mailing Address - Phone:651-762-5783
Mailing Address - Fax:651-762-9248
Practice Address - Street 1:8650 HUDSON BLVD N
Practice Address - Street 2:105
Practice Address - City:LAKE ELMO
Practice Address - State:MN
Practice Address - Zip Code:55042-9747
Practice Address - Country:US
Practice Address - Phone:651-636-1072
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND109921223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
U90286Medicare UPIN