Provider Demographics
NPI:1881997682
Name:WANG, JOHN (DDS)
Entity type:Individual
Prefix:
First Name:JOHN
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:PO BOX 160
Mailing Address - Street 2:
Mailing Address - City:SHIPROCK
Mailing Address - State:NM
Mailing Address - Zip Code:87420-0160
Mailing Address - Country:US
Mailing Address - Phone:928-656-5000
Mailing Address - Fax:
Practice Address - Street 1:US HWY 160 & NAVAJO ROUTE 35 - RED MESA
Practice Address - Street 2:
Practice Address - City:TEECNOSPOS
Practice Address - State:AZ
Practice Address - Zip Code:86514
Practice Address - Country:US
Practice Address - Phone:928-656-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-16
Last Update Date:2021-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA600571223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice