Provider Demographics
NPI:1194019901
Name:WAN, ANDY (DDS)
Entity Type:Individual
Prefix:DR
First Name:ANDY
Middle Name:
Last Name:WAN
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 1:210 CANAL ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10013-4155
Mailing Address - Country:US
Mailing Address - Phone:212-385-0001
Mailing Address - Fax:
Practice Address - Street 1:4422 THIRD AVENUE
Practice Address - Street 2:ST. BARNABAS HOSPITAL/MILLS BUILDING - DENTAL
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10457
Practice Address - Country:US
Practice Address - Phone:718-332-9888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-09
Last Update Date:2012-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY056280122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist