Provider Demographics
NPI:1194173971
Name:VANG, LAO
Entity type:Individual
Prefix:
First Name:LAO
Middle Name:
Last Name:VANG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5700 BOTTINEAU BLVD STE 270
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL
Mailing Address - State:MN
Mailing Address - Zip Code:55429-2671
Mailing Address - Country:US
Mailing Address - Phone:763-210-8222
Mailing Address - Fax:763-280-7511
Practice Address - Street 1:10616 KYLE AVE N
Practice Address - Street 2:
Practice Address - City:BROOKLYN PARK
Practice Address - State:MN
Practice Address - Zip Code:55443-1250
Practice Address - Country:US
Practice Address - Phone:763-221-0361
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-02
Last Update Date:2020-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND13678122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist