MEDICARE: ROBERT KEN 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	30662	CA

General Provider Information

NPI Number	:	1205914678
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ROBERT KEN WONG D.D.S.

Provider Business Mailing Address
First Line	:	34117 FREMONT BLVD
Second Line	:
City	:	FREMONT
State	:	CA
Zip	:	94555-2230
Country	:	US
Telephone Number	:	510-795-0307
Fax Number	:

Provider Business Practice Location Address
First Line	:	34117 FREMONT BLVD
Second Line	:
City	:	FREMONT
State	:	CA
Zip	:	94555-2230
Country	:	US
Telephone Number	:	510-795-0307
Fax Number	:

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

Provider Enumeration Date	:	11/01/2006
Last Update Date	:	07/08/2007

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