Healthcare Provider Details

I. General information

NPI: 1053966705
Provider Name (Legal Business Name): HARRISON WONG DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/08/2019
Last Update Date: 04/30/2021
Certification Date: 04/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6711 GREENLEAF AVE
WHITTIER CA
90601-4110
US

IV. Provider business mailing address

10535 WILSHIRE BLVD APT 1412
LOS ANGELES CA
90024-4564
US

V. Phone/Fax

Practice location:
  • Phone: 562-698-0054
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number105081
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: