Provider Demographics
NPI:1124047550
Name:WANG, DERRICK I (DMD)
Entity type:Individual
Prefix:DR
First Name:DERRICK
Middle Name:I
Last Name:WANG
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1959 NE PACIFIC ST
Mailing Address - Street 2:D663A
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98195-7448
Mailing Address - Country:US
Mailing Address - Phone:206-616-1758
Mailing Address - Fax:
Practice Address - Street 1:1959 NE PACIFIC ST
Practice Address - Street 2:D663A
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98195-7448
Practice Address - Country:US
Practice Address - Phone:206-616-1758
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2016-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000108481223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics