Healthcare Provider Details

I. General information

NPI: 1659575207
Provider Name (Legal Business Name): PAUL I-CHUN WANG D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2007
Last Update Date: 03/11/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 BERKELEY SQ
BERKELEY CA
94704-1206
US

IV. Provider business mailing address

218 ELWORTHY RANCH DR
DANVILLE CA
94526-4845
US

V. Phone/Fax

Practice location:
  • Phone: 510-982-0300
  • Fax:
Mailing address:
  • Phone: 415-760-9169
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number19750
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number19750
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number63513
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number63513
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: