Healthcare Provider Details

I. General information

NPI: 1871904896
Provider Name (Legal Business Name): RAYMOND S WANG DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2014
Last Update Date: 02/12/2021
Certification Date: 01/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7170 INDIANA AVE
RIVERSIDE CA
92504-4544
US

IV. Provider business mailing address

7170 INDIANA AVE
RIVERSIDE CA
92504-4544
US

V. Phone/Fax

Practice location:
  • Phone: 951-248-0567
  • Fax:
Mailing address:
  • Phone: 714-363-6928
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number63369
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number63369
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: