Provider Demographics
NPI:1013064070
Name:WANG, BENJAMIN (DMD)
Entity type:Individual
Prefix:DR
First Name:BENJAMIN
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 1:610 SW ALDER ST
Mailing Address - Street 2:SUITE 1105
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97205-3625
Mailing Address - Country:US
Mailing Address - Phone:503-228-1506
Mailing Address - Fax:503-228-1499
Practice Address - Street 1:610 SW ALDER ST
Practice Address - Street 2:SUITE 1105
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97205-3625
Practice Address - Country:US
Practice Address - Phone:503-228-1506
Practice Address - Fax:503-228-1499
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2008-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD8313122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist