Provider Demographics
NPI:1144549684
Name:JEFFREY WANG, DDS
Entity type:Organization
Organization Name:JEFFREY WANG, DDS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:DI
Authorized Official - Last Name:WANG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:510-791-2080
Mailing Address - Street 1:34420 FREMONT BLVD
Mailing Address - Street 2:#C
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94555
Mailing Address - Country:US
Mailing Address - Phone:510-791-2080
Mailing Address - Fax:510-791-1496
Practice Address - Street 1:34420 FREMONT BLVD
Practice Address - Street 2:#C
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94555
Practice Address - Country:US
Practice Address - Phone:510-791-2080
Practice Address - Fax:510-791-1496
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-24
Last Update Date:2010-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA49705122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty