MEDICARE: GW DENTAL STUDIO PC

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	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1386467512
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GW DENTAL STUDIO PC

Provider Business Mailing Address
First Line	:	20726 NORTHERN BLVD STE 2B
Second Line	:
City	:	BAYSIDE
State	:	NY
Zip	:	11361-3147
Country	:	US
Telephone Number	:	718-885-4323
Fax Number	:

Provider Business Practice Location Address
First Line	:	20726 NORTHERN BLVD STE 2B
Second Line	:
City	:	BAYSIDE
State	:	NY
Zip	:	11361-3147
Country	:	US
Telephone Number	:	718-885-4323
Fax Number	:	718-885-4325

Authorized Official
Title or Position	:	DENTIST
Name	:	DR. GORDON WANG
Credential	:	DDS
Telephone Number	:	646-703-4376

Provider Enumeration Date	:	11/06/2024
Last Update Date	:	01/16/2026

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