Healthcare Provider Details

I. General information

NPI: 1508306267
Provider Name (Legal Business Name): CONNIE WANG DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/28/2017
Last Update Date: 12/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

930 16TH ST
SAN FRANCISCO CA
94107
US

IV. Provider business mailing address

1333 MARTIN LUTHER KING DR
HAYWARD CA
94541-4397
US

V. Phone/Fax

Practice location:
  • Phone: 415-890-4449
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number103095
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: