Provider Demographics
NPI:1083042204
Name:WANG, GREGORY (DDS)
Entity type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:
Last Name:WANG
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22010 17TH AVE SE STE B
Mailing Address - Street 2:
Mailing Address - City:BOTHELL
Mailing Address - State:WA
Mailing Address - Zip Code:98021-8486
Mailing Address - Country:US
Mailing Address - Phone:425-481-8571
Mailing Address - Fax:
Practice Address - Street 1:22010 17TH AVE SE STE B
Practice Address - Street 2:
Practice Address - City:BOTHELL
Practice Address - State:WA
Practice Address - Zip Code:98021-8486
Practice Address - Country:US
Practice Address - Phone:425-481-8571
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-10-25
Last Update Date:2024-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA607898411223G0001X
TX303751223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice