MEDICARE: WAIJUN JESSICA WONG

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	390200000X	Student in an Organized Health Care Education/Training Program
2	122300000X	Dentist	061367	NY

General Provider Information

NPI Number	:	1326504663
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WAIJUN JESSICA WONG

Provider Business Mailing Address
First Line	:	3237 58TH ST APT 2
Second Line	:
City	:	WOODSIDE
State	:	NY
Zip	:	11377-2025
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	446 FAIRVIEW AVE STE 100
Second Line	:
City	:	HUDSON
State	:	NY
Zip	:	12534-1048
Country	:	US
Telephone Number	:	518-267-3272
Fax Number	:

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

Provider Enumeration Date	:	02/12/2019
Last Update Date	:	09/15/2020

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