Provider Demographics
NPI:1942695457
Name:SOUTH SHORE DENTAL
Entity Type:Organization
Organization Name:SOUTH SHORE DENTAL
Other - Org Name:MATTHEW LAU, DDS INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:JIN
Authorized Official - Last Name:LAU
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:510-846-8556
Mailing Address - Street 1:2111 WHITEHALL PL STE C
Mailing Address - Street 2:
Mailing Address - City:ALAMEDA
Mailing Address - State:CA
Mailing Address - Zip Code:94501-6160
Mailing Address - Country:US
Mailing Address - Phone:510-523-5323
Mailing Address - Fax:
Practice Address - Street 1:2111 WHITEHALL PL STE C
Practice Address - Street 2:
Practice Address - City:ALAMEDA
Practice Address - State:CA
Practice Address - Zip Code:94501-6160
Practice Address - Country:US
Practice Address - Phone:510-523-5323
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-01
Last Update Date:2015-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA58875122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1417282187OtherINDIVIDUAL NPI
CA58875OtherDENTAL LICENSE