Provider Demographics
NPI:1679764278
Name:ANDREW C. WANG DDS
Entity type:Organization
Organization Name:ANDREW C. WANG DDS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:C
Authorized Official - Last Name:WANG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:916-427-8918
Mailing Address - Street 1:905 SECRET RIVER DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95831-3437
Mailing Address - Country:US
Mailing Address - Phone:916-427-8918
Mailing Address - Fax:
Practice Address - Street 1:905 SECRET RIVER DR
Practice Address - Street 2:SUITE B
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95831-3437
Practice Address - Country:US
Practice Address - Phone:916-427-8918
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-08
Last Update Date:2007-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA033168305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA033168OtherCALIFORNIA DENTAL LICENSE