MEDICARE: DR. AGNES LAU DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	16139	MA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1780675819
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. AGNES LAU DMD

Provider Business Mailing Address
First Line	:	PO BOX 9142
Second Line	:	MASS GENERAL PHYSICIAN ORGANIZATION
City	:	CHARLESTOWN
State	:	MA
Zip	:	02129-9142
Country	:	US
Telephone Number	:	617-724-0287
Fax Number	:	617-726-2894

Provider Business Practice Location Address
First Line	:	165 CAMBRIDGE ST
Second Line	:	MGH DENTAL GROUP SUITE 401
City	:	BOSTON
State	:	MA
Zip	:	02114-2783
Country	:	US
Telephone Number	:	617-726-1076
Fax Number	:	617-724-6681

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/28/2005
Last Update Date	:	09/26/2011

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