Healthcare Provider Details

I. General information

NPI: 1720244247
Provider Name (Legal Business Name): WAYNE WU DENTAL CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/04/2008
Last Update Date: 05/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14976 SAND CANYON AVE
IRVINE CA
92618
US

IV. Provider business mailing address

14976 SAND CANYON AVE
IRVINE CA
92618
US

V. Phone/Fax

Practice location:
  • Phone: 949-788-0088
  • Fax:
Mailing address:
  • Phone: 949-788-0088
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number50694
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number40065
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number46349
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number44128
License Number StateCA

VIII. Authorized Official

Name: DR. WAYNE I WU
Title or Position: CEO
Credential: D.D.S.
Phone: 949-788-0088