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General NPI Number Information
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NPI Number | 1073193348
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Entity Type | Individual
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Provider Name | MARISSA WANG DMD
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Gender | Female
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Dates
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Enumeration Date | 04/12/2021
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Last Update Date | 04/12/2021
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Provider Practice Location Address
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Address Line | 3110 KERNER BLVD
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City | SAN RAFAEL
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State | CA
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Zip | 94901-5411
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Country | US
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Telephone | 626-297-0068
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Fax |
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Provider Business Mailing Address
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Address Line | 11911 LAMBERT AVE
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City | EL MONTE
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State | CA
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Zip | 91732-2031
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Country | US
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Telephone | 626-297-0068
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 105449
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License Number State | CA
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