Provider Demographics
NPI:1407905250
Name:WANG, ANDREW C (DDS)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:C
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 1:905 SECRET RIVER DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95831-3437
Mailing Address - Country:US
Mailing Address - Phone:916-427-8918
Mailing Address - Fax:
Practice Address - Street 1:905 SECRET RIVER DR
Practice Address - Street 2:SUITE B
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95831-3437
Practice Address - Country:US
Practice Address - Phone:916-427-8918
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA0331681223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA033168OtherDENTAL LICENSE NUMBER
CAB33168-01OtherDENTI-CAL PROVIDER NUMBER