=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376754507
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RAYMOND AU & AUGUSTINE AU DDS PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/28/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 121 N 10TH ST
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19107-2402
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-923-1304
-----------------------------------------------------
Fax | 215-923-5730
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 121 N 10TH ST
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19107-2402
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-923-1304
-----------------------------------------------------
Fax | 215-923-5730
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PARTNER
-----------------------------------------------------
Name | DR. AUGUSTINE CHI-KUEN AU
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 215-923-1304
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | DS 021021 L
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------