Provider Demographics
NPI:1902223969
Name:SU, WADE (DMD)
Entity Type:Individual
Prefix:DR
First Name:WADE
Middle Name:
Last Name:SU
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 1:18822 NORWALK BLVD
Mailing Address - Street 2:
Mailing Address - City:ARTESIA
Mailing Address - State:CA
Mailing Address - Zip Code:90701-5973
Mailing Address - Country:US
Mailing Address - Phone:562-809-3899
Mailing Address - Fax:562-865-1221
Practice Address - Street 1:18822 NORWALK BLVD
Practice Address - Street 2:
Practice Address - City:ARTESIA
Practice Address - State:CA
Practice Address - Zip Code:90701-5973
Practice Address - Country:US
Practice Address - Phone:562-809-3899
Practice Address - Fax:562-865-1221
Is Sole Proprietor?:No
Enumeration Date:2014-03-27
Last Update Date:2014-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA631451223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice