Provider Demographics
NPI:1205562253
Name:WANG, LISA (DDS)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:WANG
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 N 85TH ST UNIT 312
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98103-3869
Mailing Address - Country:US
Mailing Address - Phone:206-430-3869
Mailing Address - Fax:
Practice Address - Street 1:2045 WESTLAKE AVE
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98121-2605
Practice Address - Country:US
Practice Address - Phone:206-207-0200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-30
Last Update Date:2022-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE61324360122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist