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General NPI Number Information
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NPI Number | 1194173971
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Entity Type | Individual
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Provider Name | LAO VANG
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Gender | Male
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Dates
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Enumeration Date | 06/02/2016
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Last Update Date | 02/20/2020
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Provider Practice Location Address
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Address Line | 10616 KYLE AVE N
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City | BROOKLYN PARK
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State | MN
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Zip | 55443-1250
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Country | US
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Telephone | 763-221-0361
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Fax |
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Provider Business Mailing Address
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Address Line | 5700 BOTTINEAU BLVD STE 270
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City | CRYSTAL
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State | MN
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Zip | 55429-2671
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Country | US
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Telephone | 763-210-8222
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Fax | 763-280-7511
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | D13678
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License Number State | MN
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