Provider Demographics
NPI:1073193348
Name:WANG, MARISSA (DMD)
Entity Type:Individual
Prefix:DR
First Name:MARISSA
Middle Name:
Last Name:WANG
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 1:11911 LAMBERT AVE
Mailing Address - Street 2:
Mailing Address - City:EL MONTE
Mailing Address - State:CA
Mailing Address - Zip Code:91732-2031
Mailing Address - Country:US
Mailing Address - Phone:626-297-0068
Mailing Address - Fax:
Practice Address - Street 1:3110 KERNER BLVD
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901-5411
Practice Address - Country:US
Practice Address - Phone:626-297-0068
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-12
Last Update Date:2021-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1054491223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice