Provider Demographics
NPI:1619027620
Name:WANG, ICHUNG (DDS)
Entity type:Individual
Prefix:DR
First Name:ICHUNG
Middle Name:
Last Name:WANG
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:JOHNNY
Other - Middle Name:
Other - Last Name:WANG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:PO BOX 357131
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98195-7131
Mailing Address - Country:US
Mailing Address - Phone:206-616-8794
Mailing Address - Fax:
Practice Address - Street 1:1959 NE PACIFIC ST
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98195-7131
Practice Address - Country:US
Practice Address - Phone:206-616-8794
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACS100004171223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics