Provider Demographics
NPI:1780675819
Name:LAU, AGNES (DMD)
Entity Type:Individual
Prefix:DR
First Name:AGNES
Middle Name:
Last Name:LAU
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:PO BOX 9142
Mailing Address - Street 2:MASS GENERAL PHYSICIAN ORGANIZATION
Mailing Address - City:CHARLESTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02129-9142
Mailing Address - Country:US
Mailing Address - Phone:617-724-0287
Mailing Address - Fax:617-726-2894
Practice Address - Street 1:165 CAMBRIDGE ST
Practice Address - Street 2:MGH DENTAL GROUP SUITE 401
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-2783
Practice Address - Country:US
Practice Address - Phone:617-726-1076
Practice Address - Fax:617-724-6681
Is Sole Proprietor?:No
Enumeration Date:2005-10-28
Last Update Date:2011-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA16139122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0273074Medicaid
MA0273074Medicaid