Provider Demographics
NPI:1821586041
Name:WU, JONATHAN PC (DDS)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:PC
Last Name:WU
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 1:3916 PRINCE ST STE M52
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11354-5368
Mailing Address - Country:US
Mailing Address - Phone:929-266-9888
Mailing Address - Fax:
Practice Address - Street 1:3916 PRINCE ST STE M52
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11354
Practice Address - Country:US
Practice Address - Phone:929-266-9888
Practice Address - Fax:929-266-9889
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-23
Last Update Date:2019-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY0606211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program