Provider Demographics
NPI:1952075152
Name:LAUREL DENTAL SAN MATEO
Entity Type:Organization
Organization Name:LAUREL DENTAL SAN MATEO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JEAN
Authorized Official - Middle Name:
Authorized Official - Last Name:WU
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:650-232-9025
Mailing Address - Street 1:1267 LAUREL ST
Mailing Address - Street 2:
Mailing Address - City:SAN CARLOS
Mailing Address - State:CA
Mailing Address - Zip Code:94070-5015
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 S EL CAMINO REAL
Practice Address - Street 2:
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94401-3810
Practice Address - Country:US
Practice Address - Phone:650-232-9025
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-03
Last Update Date:2021-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental