Provider Demographics
NPI:1205453149
Name:CHUANDI WANG PEDIATRIC DENTISTRY PC
Entity type:Organization
Organization Name:CHUANDI WANG PEDIATRIC DENTISTRY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:CHUANDI
Authorized Official - Middle Name:
Authorized Official - Last Name:WANG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-267-5876
Mailing Address - Street 1:5907 OAKLAND DR
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49024-1120
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5907 OAKLAND DR
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024-1120
Practice Address - Country:US
Practice Address - Phone:269-327-4459
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-26
Last Update Date:2020-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty