Provider Demographics
NPI:1548430044
Name:WAN, GEOFFREY ANDREW (DDS)
Entity type:Individual
Prefix:DR
First Name:GEOFFREY
Middle Name:ANDREW
Last Name:WAN
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 1:10495 NE 4TH ST.
Mailing Address - Street 2:APT N244
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98004-2305
Mailing Address - Country:US
Mailing Address - Phone:330-402-7891
Mailing Address - Fax:
Practice Address - Street 1:6607 WEST CANAL DR.
Practice Address - Street 2:
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99336-5077
Practice Address - Country:US
Practice Address - Phone:330-884-3058
Practice Address - Fax:330-884-5788
Is Sole Proprietor?:No
Enumeration Date:2008-03-11
Last Update Date:2009-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE6077598122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist