Provider Demographics
NPI:1386109213
Name:WANG, PHILIP (DMD/DDS)
Entity type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:
Last Name:WANG
Suffix:
Gender:M
Credentials:DMD/DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 VIA BERRENDO
Mailing Address - Street 2:
Mailing Address - City:RANCHO SANTA MARGARITA
Mailing Address - State:CA
Mailing Address - Zip Code:92688-3194
Mailing Address - Country:US
Mailing Address - Phone:760-889-2312
Mailing Address - Fax:
Practice Address - Street 1:1208 W FRANCISQUITO AVE
Practice Address - Street 2:
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91790-4780
Practice Address - Country:US
Practice Address - Phone:626-964-9200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-05
Last Update Date:2019-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA103433122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist