MEDICARE: EDWARD WANG

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	110975	CA

General Provider Information

NPI Number	:	1093530073
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EDWARD WANG

Provider Business Mailing Address
First Line	:	1408 S SAN GABRIEL BLVD
Second Line	:
City	:	SAN GABRIEL
State	:	CA
Zip	:	91776-3603
Country	:	US
Telephone Number	:	626-382-6969
Fax Number	:

Provider Business Practice Location Address
First Line	:	1408 S SAN GABRIEL BLVD
Second Line	:
City	:	SAN GABRIEL
State	:	CA
Zip	:	91776-3603
Country	:	US
Telephone Number	:	626-572-7211
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/15/2024
Last Update Date	:	11/15/2024

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Directions to “ EDWARD WANG ” Practice Location

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