Provider Demographics
NPI:1962577593
Name:WAN, SU FONG DAVID (DDS)
Entity type:Individual
Prefix:DR
First Name:SU FONG
Middle Name:DAVID
Last Name:WAN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1990 POST OAK BLVD STE H
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77056-3844
Mailing Address - Country:US
Mailing Address - Phone:832-659-0977
Mailing Address - Fax:832-659-0071
Practice Address - Street 1:1990 POST OAK BLVD STE H
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77056-3844
Practice Address - Country:US
Practice Address - Phone:832-659-0977
Practice Address - Fax:832-659-0071
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2013-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX225501223G0001X, 1223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
No1223G0001XDental ProvidersDentistGeneral Practice