Provider Demographics
NPI:1255666228
Name:WAN, DEVON LIA-SOAN (DMD)
Entity Type:Individual
Prefix:
First Name:DEVON
Middle Name:LIA-SOAN
Last Name:WAN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3512 SEAHORN CIR.
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92130
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1809 NATIONAL AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92113-2113
Practice Address - Country:US
Practice Address - Phone:619-515-2394
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-08
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA605471223G0001X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program