Healthcare Provider Details

I. General information

NPI: 1437068756
Provider Name (Legal Business Name): FANNY WONG
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/02/2026
Last Update Date: 09/02/2026
Certification Date: 09/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1520 STOCKTON ST
SAN FRANCISCO CA
94133-3354
US

IV. Provider business mailing address

151 MADDUX AVE
SAN FRANCISCO CA
94124-2211
US

V. Phone/Fax

Practice location:
  • Phone: 888-500-1886
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDDS113106
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: