Provider Demographics
NPI:1164614418
Name:WAN, AMELIA AM (DDS)
Entity Type:Individual
Prefix:DR
First Name:AMELIA
Middle Name:AM
Last Name:WAN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1602 LIBERTY DRIVE
Mailing Address - Street 2:
Mailing Address - City:THOMASVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27360-5750
Mailing Address - Country:US
Mailing Address - Phone:336-475-8181
Mailing Address - Fax:336-475-9223
Practice Address - Street 1:1602 LIBERTY DRIVE
Practice Address - Street 2:
Practice Address - City:THOMASVILLE
Practice Address - State:NC
Practice Address - Zip Code:27360-5750
Practice Address - Country:US
Practice Address - Phone:336-475-8181
Practice Address - Fax:336-475-9223
Is Sole Proprietor?:No
Enumeration Date:2007-08-10
Last Update Date:2017-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDTP 4841223G0001X
NC94141223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice