MEDICARE: TOM KEH JENS WANG A PROFESSIONAL DENTAL CORP

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	32223	CA

General Provider Information

NPI Number	:	1699897223
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TOM KEH JENS WANG A PROFESSIONAL DENTAL CORP

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	:	626-572-7211
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	:	PRESIDENT
Name	:	TOM K J WANG
Credential	:	DDS
Telephone Number	:	626-572-7211

Provider Enumeration Date	:	04/04/2007
Last Update Date	:	08/22/2020

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