=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336613512
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHAEL WANG DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/21/2019
-----------------------------------------------------
Last Update Date | 07/02/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10414 VACCO ST
-----------------------------------------------------
City | SOUTH EL MONTE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91733-3350
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-281-3383
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 419 N CHANDLER AVE UNIT 423
-----------------------------------------------------
City | MONTEREY PARK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91754-7785
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 408-858-2298
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 111629
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------