Healthcare Provider Details

I. General information

NPI: 1467631325
Provider Name (Legal Business Name): KYLE R WONG DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/29/2007
Last Update Date: 09/25/2024
Certification Date: 09/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

416 W LAS TUNAS DR STE 102
SAN GABRIEL CA
91776-1236
US

IV. Provider business mailing address

416 W LAS TUNAS DR STE 102
SAN GABRIEL CA
91776-1236
US

V. Phone/Fax

Practice location:
  • Phone: 626-282-2068
  • Fax:
Mailing address:
  • Phone: 626-478-8813
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number35355
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number9165
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: