Healthcare Provider Details

I. General information

NPI: 1003457441
Provider Name (Legal Business Name): MADISON DENTISTRY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/07/2019
Last Update Date: 10/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

268 MAIN STREET, SUITE B
MADISON NJ
07940
US

IV. Provider business mailing address

268 MAIN STREET, SUITE B
MADISON NJ
07940
US

V. Phone/Fax

Practice location:
  • Phone: 973-822-8003
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State

VIII. Authorized Official

Name: DR. JENNY LAU
Title or Position: DENTIST
Credential: DMD
Phone: 917-667-1488