MEDICARE: COASTAL PEDIATRIC DENTAL & ANESTHESIA, PLLC

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	1223P0221X	Pediatric Dentistry	0401413751	VA
2	122300000X	Dentist	0401414467	VA
3	1223D0004X	Dental Anesthesiology	0447000045	VA

General Provider Information

NPI Number	:	1184155962
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COASTAL PEDIATRIC DENTAL & ANESTHESIA, PLLC

Provider Business Mailing Address
First Line	:	303 55TH ST UNIT A
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23451-2213
Country	:	US
Telephone Number	:	602-799-1748
Fax Number	:

Provider Business Practice Location Address
First Line	:	6161 KEMPSVILLE CIR
Second Line	:	SUITE 345
City	:	NORFOLK
State	:	VA
Zip	:	23502-3932
Country	:	US
Telephone Number	:	602-799-1748
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. JONATHAN L WONG
Credential	:	DMD
Telephone Number	:	757-963-0001

Provider Enumeration Date	:	03/23/2017
Last Update Date	:	03/24/2026

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