MEDICARE: DR. MARTIN DAVID WONG D.M.D

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	034798	CA

General Provider Information

NPI Number	:	1174603906
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARTIN DAVID WONG D.M.D

Provider Business Mailing Address
First Line	:	2970 HILLTOP MALL RD
Second Line	:	SUITE 212
City	:	RICHMOND
State	:	CA
Zip	:	94806-1947
Country	:	US
Telephone Number	:	510-222-4178
Fax Number	:	510-222-8677

Provider Business Practice Location Address
First Line	:	2970 HILLTOP MALL RD
Second Line	:	SUITE 212
City	:	RICHMOND
State	:	CA
Zip	:	94806-1947
Country	:	US
Telephone Number	:	510-222-4178
Fax Number	:	510-222-8677

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

Provider Enumeration Date	:	10/16/2006
Last Update Date	:	07/08/2007

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