MEDICARE: MR. KENNETH LOREN WONG D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	29187	CA

General Provider Information

NPI Number	:	1003991605
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. KENNETH LOREN WONG D.D.S.

Provider Business Mailing Address
First Line	:	2041 POLK ST STE B
Second Line	:
City	:	SAN FRANCISCO
State	:	CA
Zip	:	94109-2549
Country	:	US
Telephone Number	:	415-776-6897
Fax Number	:	415-776-6898

Provider Business Practice Location Address
First Line	:	2041 POLK ST STE B
Second Line	:
City	:	SAN FRANCISCO
State	:	CA
Zip	:	94109-2549
Country	:	US
Telephone Number	:	415-776-6897
Fax Number	:	415-776-6898

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/25/2006
Last Update Date	:	07/08/2007

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