Provider Demographics
NPI:1316446198
Name:WANG, JUSTIN (DMD, MD)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:WANG
Suffix:
Gender:M
Credentials:DMD, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5392 S WADSWORTH BLVD UNIT 103
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80123-1271
Mailing Address - Country:US
Mailing Address - Phone:303-979-4277
Mailing Address - Fax:
Practice Address - Street 1:5392 S WADSWORTH BLVD UNIT 103
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80123-1271
Practice Address - Country:US
Practice Address - Phone:303-979-4277
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-07
Last Update Date:2023-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO002054651223S0112X
CODEN.002054651223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery