Provider Demographics
NPI:1891104006
Name:WU, RONGNING(GRACE)
Entity type:Individual
Prefix:
First Name:RONGNING(GRACE)
Middle Name:
Last Name:WU
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 1:236 CROCKER PARK BLVD APT 204
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44145-8144
Mailing Address - Country:US
Mailing Address - Phone:510-283-4422
Mailing Address - Fax:
Practice Address - Street 1:2124 CORNELL ROAD
Practice Address - Street 2:DEPARTMENT OF ORTHODONTICS
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44106-4905
Practice Address - Country:US
Practice Address - Phone:216-368-0262
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-13
Last Update Date:2014-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30.024284122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist