Healthcare Provider Details

I. General information

NPI: 1750646865
Provider Name (Legal Business Name): VICKI H. WANG DENTAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/05/2012
Last Update Date: 07/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1282 N LAKE AVE
PASADENA CA
91104-2854
US

IV. Provider business mailing address

1282 N LAKE AVE
PASADENA CA
91104-2854
US

V. Phone/Fax

Practice location:
  • Phone: 626-797-3451
  • Fax: 626-797-3431
Mailing address:
  • Phone: 626-797-3451
  • Fax: 626-797-3431

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number47206
License Number StateCA

VIII. Authorized Official

Name: DR. VICKI HYUNA WANG
Title or Position: PRESIDENT
Credential: DDS
Phone: 626-797-3451