Basic Information
Provider Information | |||||||||
NPI: | 1427251222 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WANG | ||||||||
FirstName: | SUSAN | ||||||||
MiddleName: | JENE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | DDS | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 8572 MONTICELLO AVE | ||||||||
Address2: |   | ||||||||
City: | BUENA PARK | ||||||||
State: | CA | ||||||||
PostalCode: | 906211619 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5629724466 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 501 S IDAHO STREET | ||||||||
Address2: | SUITE 190 | ||||||||
City: | LA HABRA | ||||||||
State: | CA | ||||||||
PostalCode: | 90631 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5626900400 | ||||||||
FaxNumber: | 5626903182 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/08/2007 | ||||||||
LastUpdateDate: | 01/23/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 2901019547 | MI | Y |   | Dental Providers | Dentist |   | 1223G0001X | 2901019547 | MI | N |   | Dental Providers | Dentist | General Practice |
No ID Information.