Provider Demographics
NPI:1164088860
Name:MOWA LLC
Entity Type:Organization
Organization Name:MOWA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MORLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:WANG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:917-833-2063
Mailing Address - Street 1:3626 215TH PL
Mailing Address - Street 2:
Mailing Address - City:BAYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11361-2209
Mailing Address - Country:US
Mailing Address - Phone:917-833-2063
Mailing Address - Fax:
Practice Address - Street 1:9411 59TH AVE STE A5
Practice Address - Street 2:
Practice Address - City:ELMHURST
Practice Address - State:NY
Practice Address - Zip Code:11373-5158
Practice Address - Country:US
Practice Address - Phone:718-924-2555
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-17
Last Update Date:2019-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03519275Medicaid