Healthcare Provider Details

I. General information

NPI: 1235995887
Provider Name (Legal Business Name): DANIEL WANG
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/22/2024
Last Update Date: 08/15/2024
Certification Date: 08/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

32114 1ST AVE S STE 200
FEDERAL WAY WA
98003-5760
US

IV. Provider business mailing address

32114 1ST AVE S STE 200
FEDERAL WAY WA
98003-5760
US

V. Phone/Fax

Practice location:
  • Phone: 253-838-9333
  • Fax:
Mailing address:
  • Phone: 253-838-9333
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDE61565690
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: