=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841318565
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RUSSELL WANG D.D.S., M.S.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/27/2007
-----------------------------------------------------
Last Update Date | 05/17/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10568 RAVENNA RD STE 5
-----------------------------------------------------
City | TWINSBURG
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44087-1654
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 440-446-1819
-----------------------------------------------------
Fax | 440-442-2316
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10568 RAVENNA RD STE 5
-----------------------------------------------------
City | TWINSBURG
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44087-1654
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 440-446-1819
-----------------------------------------------------
Fax | 440-442-2316
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0700X
-----------------------------------------------------
Taxonomy Name | Prosthodontics
-----------------------------------------------------
License Number | 30-020060
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------