Provider Demographics
NPI:1972173078
Name:WANG, JIA (DE61176282)
Entity type:Individual
Prefix:
First Name:JIA
Middle Name:
Last Name:WANG
Suffix:
Gender:F
Credentials:DE61176282
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7750 15TH AVE NE STE A
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98115-4314
Mailing Address - Country:US
Mailing Address - Phone:206-402-3402
Mailing Address - Fax:206-402-3460
Practice Address - Street 1:7750 15TH AVE NE STE A
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98115-4314
Practice Address - Country:US
Practice Address - Phone:415-623-0903
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-30
Last Update Date:2021-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE611762821223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice