Provider Demographics
NPI:1265445647
Name:WANG, DAVID A (DDS)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:A
Last Name:WANG
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 1:537 MURPHY RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-8187
Mailing Address - Country:US
Mailing Address - Phone:541-779-0900
Mailing Address - Fax:541-858-7973
Practice Address - Street 1:537 MURPHY RD
Practice Address - Street 2:SUITE B
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-8187
Practice Address - Country:US
Practice Address - Phone:541-779-0900
Practice Address - Fax:541-858-7973
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-15
Last Update Date:2007-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA342541223X0400X
ORD83521223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR12540958OtherBID