Provider Demographics
NPI:1306094354
Name:WAN, NKECHI A (DDS)
Entity type:Individual
Prefix:
First Name:NKECHI
Middle Name:A
Last Name:WAN
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 1:2828 E STATE BLVD
Mailing Address - Street 2:SUITE B
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46805-4761
Mailing Address - Country:US
Mailing Address - Phone:260-482-6689
Mailing Address - Fax:260-482-6948
Practice Address - Street 1:2828 E STATE BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-4761
Practice Address - Country:US
Practice Address - Phone:260-482-6689
Practice Address - Fax:260-482-6948
Is Sole Proprietor?:No
Enumeration Date:2008-09-03
Last Update Date:2008-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12011225A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist