=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013179167
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | VANESSA Y. WANG D.M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/30/2008
-----------------------------------------------------
Last Update Date | 07/16/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 145 N NARBERTH AVE FL 2
-----------------------------------------------------
City | NARBERTH
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19072-1963
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-667-6630
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 603 CONSHOHOCKEN STATE RD
-----------------------------------------------------
City | PENN VALLEY
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19072-1212
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | DS037440
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------