Provider Demographics
NPI:1255567053
Name:LAWRENCE WANG
Entity type:Organization
Organization Name:LAWRENCE WANG
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DDS
Authorized Official - Prefix:DR
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:Y
Authorized Official - Last Name:WANG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:917-584-0824
Mailing Address - Street 1:2220 65TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11204-4035
Mailing Address - Country:US
Mailing Address - Phone:917-584-0824
Mailing Address - Fax:
Practice Address - Street 1:1158 BROADWAY
Practice Address - Street 2:3RD FLOOR
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10001-7506
Practice Address - Country:US
Practice Address - Phone:917-584-0824
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-08
Last Update Date:2009-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0523361223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02713422Medicaid