Provider Demographics
NPI:1689105744
Name:WANG FAMILY DENTAL, LLC
Entity Type:Organization
Organization Name:WANG FAMILY DENTAL, LLC
Other - Org Name:PRAIRIE DENTAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTINE
Authorized Official - Middle Name:
Authorized Official - Last Name:WANG
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:630-989-6868
Mailing Address - Street 1:5712 ROSINWEED LN
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60564-1642
Mailing Address - Country:US
Mailing Address - Phone:630-989-6868
Mailing Address - Fax:
Practice Address - Street 1:2424 W INDIAN TRL STE D
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60506-1588
Practice Address - Country:US
Practice Address - Phone:630-907-0330
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-21
Last Update Date:2017-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019028748122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty