Provider Demographics
NPI:1407952245
Name:WANG, TINA L
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:L
Last Name:WANG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:ONE BROOKLINE PLACE
Mailing Address - Street 2:SUITE 506 DRS THIEL RUBIN WANG INC
Mailing Address - City:BROOKLINE
Mailing Address - State:MA
Mailing Address - Zip Code:02445
Mailing Address - Country:US
Mailing Address - Phone:617-735-8660
Mailing Address - Fax:617-735-8662
Practice Address - Street 1:ONE BROOKLINE PLACE
Practice Address - Street 2:SUITE 506 DRS THIEL RUBIN WANG INC
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02445
Practice Address - Country:US
Practice Address - Phone:617-735-8660
Practice Address - Fax:617-735-8662
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA164811223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice