Healthcare Provider Details

I. General information

NPI: 1649100595
Provider Name (Legal Business Name): SCOTT WANG
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/21/2026
Last Update Date: 05/21/2026
Certification Date: 05/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2158 VISTA WAY STE 101
OCEANSIDE CA
92054-5645
US

IV. Provider business mailing address

4428 BLACK OTTER TRL
DALLAS TX
75287-5106
US

V. Phone/Fax

Practice location:
  • Phone: 442-264-2442
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number112956
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: