Provider Demographics
NPI:1184716433
Name:WANG, MICHAEL (DDS)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:
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 1:19811 COLIMA ROAD
Mailing Address - Street 2:#510
Mailing Address - City:WALNUT
Mailing Address - State:CA
Mailing Address - Zip Code:91789
Mailing Address - Country:US
Mailing Address - Phone:909-595-3121
Mailing Address - Fax:909-595-7992
Practice Address - Street 1:19811 COLIMA ROAD
Practice Address - Street 2:#510
Practice Address - City:WALNUT
Practice Address - State:CA
Practice Address - Zip Code:91789
Practice Address - Country:US
Practice Address - Phone:909-595-3121
Practice Address - Fax:909-595-7992
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADA336841223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB3368401Medicare ID - Type Unspecified
254809Medicare UPIN