Debera Shu-Min Wang, DMD

Primary specialty

General Practice DentistryTaxonomy code 1223G0001X

License

019034731 Issued in IL

Practice address

1564 W Lane Rd
Machesney Park, IL 61115-1903

Phone

(815) 749-9838

NPI assigned

Jul 4, 2022

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Enrolled

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1656892800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1706486400000",
    "number": "1821721267",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2045 KEIM DR",
            "city": "NAPERVILLE",
            "state": "IL",
            "postal_code": "605652861",
            "telephone_number": "630-631-6342"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1564 W LANE RD",
            "city": "MACHESNEY PARK",
            "state": "IL",
            "postal_code": "611151903",
            "telephone_number": "815-749-9838"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "15100 SE 38th St",
            "address_purpose": "LOCATION",
            "city": "Bellevue",
            "state": "WA",
            "postal_code": "980061728",
            "country_code": "US",
            "telephone_number": "425-300-1019",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "WANG",
        "first_name": "DEBERA",
        "middle_name": "SHU-MIN",
        "name_prefix": "Dr.",
        "credential": "DMD",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2022-07-04",
        "last_updated": "2024-01-29",
        "certification_date": "2024-01-09",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1223G0001X",
            "taxonomy_group": "",
            "desc": "Dentist, General Practice",
            "state": "WA",
            "license": "DE61316013",
            "primary": false
        },
        {
            "code": "1223G0001X",
            "taxonomy_group": "",
            "desc": "Dentist, General Practice",
            "state": "IL",
            "license": "019034731",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• General Practice Dentistry in Machesney Park, IL
• Providers in Machesney Park, IL by specialty
• General Practice Dentistry in Illinois

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 29, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.