MEDICARE: DR. WAN-JOU RENEE WANG D.M.D.

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	63161	CA

General Provider Information

NPI Number	:	1518218965
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. WAN-JOU RENEE WANG D.M.D.

Provider Business Mailing Address
First Line	:	10855 CHURCH ST APT 513
Second Line	:
City	:	RANCHO CUCAMONGA
State	:	CA
Zip	:	91730-8570
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	12233 CENTRAL AVE
Second Line	:
City	:	CHINO
State	:	CA
Zip	:	91710-2423
Country	:	US
Telephone Number	:	909-217-3626
Fax Number	:

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

Provider Enumeration Date	:	09/25/2012
Last Update Date	:	01/24/2018

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