=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174526867
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TERRY WANG DMD, MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/27/2005
-----------------------------------------------------
Last Update Date | 07/13/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 211 MOUNT AUBURN AVE
-----------------------------------------------------
City | AUBURN
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04210-8521
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-514-7171
-----------------------------------------------------
Fax | 207-514-7177
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 211 MOUNT AUBURN AVE
-----------------------------------------------------
City | AUBURN
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04210-8521
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-514-7171
-----------------------------------------------------
Fax | 207-514-7177
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number | 3607
-----------------------------------------------------
License Number State | ME
-----------------------------------------------------