Healthcare Provider Details

I. General information

NPI: 1376704452
Provider Name (Legal Business Name): EDMUND YING-PENG WUN D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2008
Last Update Date: 05/30/2024
Certification Date: 05/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 PALISADES DR STE 250
ALBANY NY
12205-1448
US

IV. Provider business mailing address

4 PALISADES DR STE 250
ALBANY NY
12205-1448
US

V. Phone/Fax

Practice location:
  • Phone: 518-240-3750
  • Fax: 518-240-3759
Mailing address:
  • Phone: 518-240-3750
  • Fax: 518-240-3759

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number053401
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDS037964
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: