Healthcare Provider Details

I. General information

NPI: 1124047550
Provider Name (Legal Business Name): DERRICK I WANG D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 11/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1959 NE PACIFIC ST D663A
SEATTLE WA
98195-7448
US

IV. Provider business mailing address

1959 NE PACIFIC ST D663A
SEATTLE WA
98195-7448
US

V. Phone/Fax

Practice location:
  • Phone: 206-616-1758
  • Fax:
Mailing address:
  • Phone: 206-616-1758
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberDE00010848
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: