Provider Demographics
NPI:1275017634
Name:WANG, DONG (LAC)
Entity Type:Individual
Prefix:
First Name:DONG
Middle Name:
Last Name:WANG
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12533 WALSH AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90066-6609
Mailing Address - Country:US
Mailing Address - Phone:512-809-0610
Mailing Address - Fax:
Practice Address - Street 1:13315 W WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90066-5169
Practice Address - Country:US
Practice Address - Phone:310-577-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-21
Last Update Date:2018-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
G51846995OtherPASSPORT