Healthcare Provider Details

I. General information

NPI: 1316158751
Provider Name (Legal Business Name): DR. RALAN DAI MING WONG
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 SPRUCE ST STE #204
SAN FRANCISCO CA
94118-2666
US

IV. Provider business mailing address

500 SPRUCE ST STE #204
SAN FRANCISCO CA
94118-2666
US

V. Phone/Fax

Practice location:
  • Phone: 415-221-1788
  • Fax: 415-221-8361
Mailing address:
  • Phone: 415-221-1788
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number40513
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: