Healthcare Provider Details

I. General information

NPI: 1093219784
Provider Name (Legal Business Name): JOAN C WANG DDS, MS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/19/2018
Last Update Date: 11/11/2023
Certification Date: 11/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2551 N CLARK ST STE 404
CHICAGO IL
60614-7729
US

IV. Provider business mailing address

2551 N CLARK ST STE 404
CHICAGO IL
60614-7729
US

V. Phone/Fax

Practice location:
  • Phone: 773-873-6372
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number019024956
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019024956
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code1223X2210X
TaxonomyOrofacial Pain Dentistry
License Number019024956
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: