Provider Demographics
NPI:1861499949
Name:LAI, PIT KEUNG PETER (DDS)
Entity Type:Individual
Prefix:
First Name:PIT KEUNG
Middle Name:PETER
Last Name:LAI
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:635 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-2718
Mailing Address - Country:US
Mailing Address - Phone:860-347-6971
Mailing Address - Fax:860-638-6601
Practice Address - Street 1:263 MAIN ST
Practice Address - Street 2:
Practice Address - City:OLD SAYBROOK
Practice Address - State:CT
Practice Address - Zip Code:06475-2326
Practice Address - Country:US
Practice Address - Phone:860-388-4433
Practice Address - Fax:860-347-4429
Is Sole Proprietor?:No
Enumeration Date:2005-07-05
Last Update Date:2008-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0084031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004236354Medicaid