=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356015200
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DR. JU QUAN WU
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/04/2021
-----------------------------------------------------
Last Update Date | 08/04/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3730 S GESSNER RD STE C-100
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77063-5132
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 832-834-5544
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9106 BEARCOVE CIR
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77064-8896
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-837-3918
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 37650
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------