=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568170611
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WENDY W FUNG, DDS, A DENTAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/08/2022
-----------------------------------------------------
Last Update Date | 11/08/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1749 TARAVAL ST
-----------------------------------------------------
City | SAN FRANCISCO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94116-2308
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-753-0790
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5214F DIAMOND HEIGHTS BLVD # 315
-----------------------------------------------------
City | SAN FRANCISCO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94131-2175
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | WENDY FUNG
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 415-370-4336
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------