Provider Demographics
NPI:1790892487
Name:WANG, KINGSLEY LIM (DDS)
Entity Type:Individual
Prefix:
First Name:KINGSLEY
Middle Name:LIM
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 1:1100 MAIN ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:WOODLAND
Mailing Address - State:CA
Mailing Address - Zip Code:95695-3513
Mailing Address - Country:US
Mailing Address - Phone:530-207-5288
Mailing Address - Fax:530-207-5285
Practice Address - Street 1:1100 MAIN ST
Practice Address - Street 2:SUITE 100
Practice Address - City:WOODLAND
Practice Address - State:CA
Practice Address - Zip Code:95695-3513
Practice Address - Country:US
Practice Address - Phone:530-207-5288
Practice Address - Fax:530-207-5285
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2010-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA476741223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
K27341Medicare ID - Type Unspecified
K27343Medicare ID - Type Unspecified
V09058Medicare UPIN
K27342Medicare ID - Type Unspecified
K27344Medicare ID - Type Unspecified