Healthcare Provider Details

I. General information

NPI: 1164356101
Provider Name (Legal Business Name): FABIAN WONG DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2026
Last Update Date: 06/26/2026
Certification Date: 06/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

263 FARMINGTON AVE
FARMINGTON CT
06030-0001
US

IV. Provider business mailing address

577 PROSPECT AVE APT 11
WEST HARTFORD CT
06105-2924
US

V. Phone/Fax

Practice location:
  • Phone: 860-679-2000
  • Fax:
Mailing address:
  • Phone: 216-804-0014
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number14840
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: