Provider Demographics
NPI:1215205968
Name:JIMMY WU, DDS, PROFESSIONAL DENTAL CORPORATION
Entity Type:Organization
Organization Name:JIMMY WU, DDS, PROFESSIONAL DENTAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JIMMY
Authorized Official - Middle Name:
Authorized Official - Last Name:WU
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:619-992-5774
Mailing Address - Street 1:1301 YNEZ PLACE
Mailing Address - Street 2:
Mailing Address - City:CORONADO
Mailing Address - State:CA
Mailing Address - Zip Code:92118
Mailing Address - Country:US
Mailing Address - Phone:619-435-6227
Mailing Address - Fax:619-435-4117
Practice Address - Street 1:1301 YNEZ PL
Practice Address - Street 2:
Practice Address - City:CORONADO
Practice Address - State:CA
Practice Address - Zip Code:92118-2925
Practice Address - Country:US
Practice Address - Phone:619-435-6227
Practice Address - Fax:619-435-4117
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-09
Last Update Date:2011-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA47019122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty