Healthcare Provider Details

I. General information

NPI: 1184144867
Provider Name (Legal Business Name): AUDREY WANG DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/22/2017
Last Update Date: 08/30/2023
Certification Date: 08/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5780 N CAREFREE CIR
COLORADO SPRINGS CO
80917-2795
US

IV. Provider business mailing address

20415 SHAKARI CIR
YORBA LINDA CA
92887-3251
US

V. Phone/Fax

Practice location:
  • Phone: 719-300-4639
  • Fax:
Mailing address:
  • Phone: 858-472-3695
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberDEN.00205763
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: