Healthcare Provider Details

I. General information

NPI: 1750923140
Provider Name (Legal Business Name): SIYI WANG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2019
Last Update Date: 10/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4323 HILL ST
COLUMBIA SC
29207-6022
US

IV. Provider business mailing address

4323 HILL ST
COLUMBIA SC
29207-6022
US

V. Phone/Fax

Practice location:
  • Phone: 857-210-5011
  • Fax:
Mailing address:
  • Phone: 857-210-5011
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: