Provider Demographics
NPI:1922564640
Name:WANG, JONATHAN CHU
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:CHU
Last Name:WANG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 BELL AVE
Mailing Address - Street 2:
Mailing Address - City:PIEDMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94611-3403
Mailing Address - Country:US
Mailing Address - Phone:510-652-7826
Mailing Address - Fax:
Practice Address - Street 1:111 BELL AVE
Practice Address - Street 2:
Practice Address - City:PIEDMONT
Practice Address - State:CA
Practice Address - Zip Code:94611-3403
Practice Address - Country:US
Practice Address - Phone:510-652-7826
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-19
Last Update Date:2021-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1052551223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty