Healthcare Provider Details

I. General information

NPI: 1073968806
Provider Name (Legal Business Name): WANSHENG ZHU DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: ALEX ZHU DDS

II. Dates (important events)

Enumeration Date: 04/29/2016
Last Update Date: 05/12/2020
Certification Date: 05/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 N STATE ST CLINIC TOWER, SUITE A7D
LOS ANGELES CA
90033-1029
US

IV. Provider business mailing address

8631 E HERMOSA DR
SAN GABRIEL CA
91775-3006
US

V. Phone/Fax

Practice location:
  • Phone: 626-808-2756
  • Fax:
Mailing address:
  • Phone: 626-808-2756
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number100622
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number36103
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: