Provider Demographics
NPI:1851138226
Name:WANG, KATHLEEN
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:WANG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 E GIRARD AVE APT 301
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19125-3381
Mailing Address - Country:US
Mailing Address - Phone:561-267-9147
Mailing Address - Fax:
Practice Address - Street 1:1701 E MOYAMENSING AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19148-1931
Practice Address - Country:US
Practice Address - Phone:215-462-4047
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-11
Last Update Date:2024-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS044783122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist