Healthcare Provider Details

I. General information

NPI: 1164577458
Provider Name (Legal Business Name): REGINA S. WONG DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: REGINA WONG PHILLIPS

II. Dates (important events)

Enumeration Date: 01/24/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

636 S EREMLAND DR
COVINA CA
91723-3523
US

IV. Provider business mailing address

636 S EREMLAND DR
COVINA CA
91723-3523
US

V. Phone/Fax

Practice location:
  • Phone: 626-339-7277
  • Fax:
Mailing address:
  • Phone: 626-339-7277
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number036303
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: