Healthcare Provider Details

I. General information

NPI: 1780086017
Provider Name (Legal Business Name): WENDY WONG D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/18/2014
Last Update Date: 06/22/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9474 FIRESTONE BLVD
DOWNEY CA
90241-5504
US

IV. Provider business mailing address

1417 S ATLANTIC BLVD APT. 24
ALHAMBRA CA
91803-3168
US

V. Phone/Fax

Practice location:
  • Phone: 562-803-4224
  • Fax:
Mailing address:
  • Phone: 213-545-1858
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number63791
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: