Provider Demographics
NPI:1699304188
Name:LAU, JESSICA (DMD)
Entity type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:
Last Name:LAU
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:345 HARRISON AVE APT 827
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-3080
Mailing Address - Country:US
Mailing Address - Phone:650-208-6488
Mailing Address - Fax:
Practice Address - Street 1:800 BOYLSTON ST FL 2
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02199-8081
Practice Address - Country:US
Practice Address - Phone:617-259-1100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-06
Last Update Date:2021-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN18587991223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics