Provider Demographics
NPI:1023263530
Name:LAI, PETER PHONG (DDS)
Entity type:Individual
Prefix:MR
First Name:PETER
Middle Name:PHONG
Last Name:LAI
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2243 VAN NESS AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94109-2504
Mailing Address - Country:US
Mailing Address - Phone:415-441-2098
Mailing Address - Fax:
Practice Address - Street 1:2243 VAN NESS AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94109-2504
Practice Address - Country:US
Practice Address - Phone:415-441-2098
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-11-25
Last Update Date:2008-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA55533122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA55533OtherCALIFORNIA DENTAL LICENSE