Provider Demographics
NPI:1063757623
Name:WU, DI (DDS)
Entity type:Individual
Prefix:DR
First Name:DI
Middle Name:
Last Name:WU
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6655 TRAVIS ST
Mailing Address - Street 2:#460, PEDIATRIC DENTISTRY
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030-1312
Mailing Address - Country:US
Mailing Address - Phone:734-945-0451
Mailing Address - Fax:
Practice Address - Street 1:6655 TRAVIS ST
Practice Address - Street 2:#460, PEDIATRIC DENTISTRY
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-1312
Practice Address - Country:US
Practice Address - Phone:734-945-0451
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-06
Last Update Date:2017-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010208511223P0221X, 390200000X
TX303841223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX3390767-01Medicaid