MEDICARE: MARISSA WANG DENTAL CORPORATION

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	1223D0001X	Public Health Dentistry

General Provider Information

NPI Number	:	1467107011
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MARISSA WANG DENTAL CORPORATION

Provider Business Mailing Address
First Line	:	2261 MARKET ST # 4502
Second Line	:
City	:	SAN FRANCISCO
State	:	CA
Zip	:	94114-1612
Country	:	US
Telephone Number	:	626-297-0068
Fax Number	:

Provider Business Practice Location Address
First Line	:	1763 UNION ST
Second Line	:
City	:	SAN FRANCISCO
State	:	CA
Zip	:	94123-4406
Country	:	US
Telephone Number	:	415-440-9000
Fax Number	:

Authorized Official
Title or Position	:	DENTIST
Name	:	DR. MARISSA WANG
Credential	:	DMD
Telephone Number	:	415-440-9000

Provider Enumeration Date	:	02/12/2022
Last Update Date	:	02/12/2022

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