Healthcare Provider Details

I. General information

NPI: 1194732685
Provider Name (Legal Business Name): HAM SANG WONG D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8085 BROADWAY
LEMON GROVE CA
91945-2533
US

IV. Provider business mailing address

8085 BROADWAY
LEMON GROVE CA
91945-2533
US

V. Phone/Fax

Practice location:
  • Phone: 619-469-8257
  • Fax: 619-469-2606
Mailing address:
  • Phone: 619-469-8257
  • Fax: 619-469-2606

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number48695
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: