Healthcare Provider Details

I. General information

NPI: 1922455542
Provider Name (Legal Business Name): WOW DENTAL FOR KIDS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2016
Last Update Date: 05/24/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1077 LEXINGTON ST
WALTHAM MA
02452-7233
US

IV. Provider business mailing address

1077 LEXINGTON ST
WALTHAM MA
02452-7233
US

V. Phone/Fax

Practice location:
  • Phone: 781-899-0014
  • Fax:
Mailing address:
  • Phone: 781-899-0014
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberMA18640
License Number StateMA

VIII. Authorized Official

Name: CHUN YU YOGI CHEN
Title or Position: OWNER
Credential:
Phone: 508-904-8670