MEDICARE: WONG FAMILY DENTAL CENTER, PA

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	DN0011013	FL

General Provider Information

NPI Number	:	1336153337
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WONG FAMILY DENTAL CENTER, PA

Provider Business Mailing Address
First Line	:	330 S LAKE SHORE WAY
Second Line	:
City	:	LAKE ALFRED
State	:	FL
Zip	:	33850-2750
Country	:	US
Telephone Number	:	863-956-2700
Fax Number	:	863-956-2770

Provider Business Practice Location Address
First Line	:	330 S LAKE SHORE WAY
Second Line	:
City	:	LAKE ALFRED
State	:	FL
Zip	:	33850-2750
Country	:	US
Telephone Number	:	863-956-2700
Fax Number	:	863-956-2770

Authorized Official
Title or Position	:	OWNER
Name	:	ANTHONY IGNATIUS WONG
Credential	:	DDS
Telephone Number	:	863-956-2700

Provider Enumeration Date	:	07/28/2006
Last Update Date	:	01/13/2015

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