Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0300X | Periodontist | 64230 | CA |
NPI | 1104201094 |
---|---|
Provider Name | Jonathan Weng |
First Address | San Francisco, CA 94143-0001 |
Second Address | San Francisco, CA 94143-0001 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 21/07/2015 |
Last Update Date | 21/07/2015 |