Provider Demographics
NPI:1740590777
Name:WANG, DERICK (DMD)
Entity Type:Individual
Prefix:DR
First Name:DERICK
Middle Name:
Last Name:WANG
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12803 WEST AVE
Mailing Address - Street 2:APT 19207
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78216-1813
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1455 AUSTIN HWY
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78209-4455
Practice Address - Country:US
Practice Address - Phone:412-897-0174
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-08
Last Update Date:2014-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS038440122300000X
TX29793122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist