Basic Information
| Provider Information | |||||||||
| NPI: | 1376629659 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WANG | ||||||||
| FirstName: | LI | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 860 HARRISON AVE | ||||||||
| Address2: | APT # 1206 | ||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021184002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6178380889 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2181 WASHINGTON ST | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | ROXBURY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021192082 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6174275665 | ||||||||
| FaxNumber: | 6174452708 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/28/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 21577 | MA | Y | Dental Providers | Dentist |
No ID Information.