Healthcare Provider Details

I. General information

NPI: 1265529366
Provider Name (Legal Business Name): GUANGQIANG WANG D.M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: MARK GUANGQIANG WANG D.M.D

II. Dates (important events)

Enumeration Date: 10/09/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19 WHITE ST
CAMBRIDGE MA
02140-1413
US

IV. Provider business mailing address

4 WELCH RD
LEXINGTON MA
02421-7519
US

V. Phone/Fax

Practice location:
  • Phone: 617-353-3300
  • Fax: 617-868-7537
Mailing address:
  • Phone: 781-863-6368
  • Fax: 781-863-6368

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number20514
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: