Healthcare Provider Details

I. General information

NPI: 1144754888
Provider Name (Legal Business Name): TIFFANY JIAOJIAO WANG D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/19/2017
Last Update Date: 02/28/2022
Certification Date: 02/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 55TH ST
BROOKLYN NY
11220-2508
US

IV. Provider business mailing address

2348 RALPH AVE
BROOKLYN NY
11234-5515
US

V. Phone/Fax

Practice location:
  • Phone: 718-630-6875
  • Fax:
Mailing address:
  • Phone: 718-531-0300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number061009
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: