Healthcare Provider Details

I. General information

NPI: 1720507668
Provider Name (Legal Business Name): QING WAN DDS, MS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/12/2017
Last Update Date: 06/23/2022
Certification Date: 06/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1620 DUVALL AVE NE STE B
RENTON WA
98059-3975
US

IV. Provider business mailing address

1620 DUVALL AVE NE STE B
RENTON WA
98059-3975
US

V. Phone/Fax

Practice location:
  • Phone: 425-235-4830
  • Fax:
Mailing address:
  • Phone: 425-235-4830
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDE60770716
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: