Healthcare Provider Details

I. General information

NPI: 1124005483
Provider Name (Legal Business Name): RYAN J. WANG D.D.S
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/28/2005
Last Update Date: 06/25/2020
Certification Date: 06/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

618TH DENTAL COMPANY USAG HUMPHREYS CARIUS DENTAL CLINIC UNIT 15652
APO AP
96271
US

IV. Provider business mailing address

618TH DENTAL COMPANY USAG HUMPHREYS CARIUS DENTAL CLINIC UNIT 15652
APO AP
96271
US

V. Phone/Fax

Practice location:
  • Phone: 315-737-9186
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019-024547
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: