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General NPI Number Information
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NPI Number | 1215205968
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Entity Type | Organization
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Legal Business Name | JIMMY WU, DDS, PROFESSIONAL DENTAL CORPORATION
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Dates
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Enumeration Date | 12/09/2011
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Last Update Date | 12/09/2011
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Provider Practice Location Address
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Address Line | 1301 YNEZ PL
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City | CORONADO
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State | CA
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Zip | 92118-2925
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Country | US
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Telephone | 619-435-6227
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Fax | 619-435-4117
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Provider Business Mailing Address
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Address Line | 1301 YNEZ PLACE
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City | CORONADO
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State | CA
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Zip | 92118
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Country | US
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Telephone | 619-435-6227
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Fax | 619-435-4117
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Authorized Official
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Title or Position | CEO/DENTIST
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Name | DR. JIMMY WU
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Credential | DDS
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Telephone | 619-992-5774
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 47019
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License Number State | CA
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