MEDICARE: DR. DERICK WANG DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	DS038440	PA
2	122300000X	Dentist	29793	TX

General Provider Information

NPI Number	:	1740590777
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DERICK WANG DMD

Provider Business Mailing Address
First Line	:	12803 WEST AVE
Second Line	:	APT 19207
City	:	SAN ANTONIO
State	:	TX
Zip	:	78216-1813
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1455 AUSTIN HWY
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78209-4455
Country	:	US
Telephone Number	:	412-897-0174
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/08/2010
Last Update Date	:	07/24/2014

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