Healthcare Provider Details

I. General information

NPI: 1245767425
Provider Name (Legal Business Name): TITUS WONGK DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/18/2017
Last Update Date: 12/18/2025
Certification Date: 12/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5901 PEACHTREE DUNWOODY RD STE B250
ATLANTA GA
30328-7150
US

IV. Provider business mailing address

5901 PEACHTREE DUNWOODY RD STE B250
ATLANTA GA
30328-7150
US

V. Phone/Fax

Practice location:
  • Phone: 470-713-6770
  • Fax:
Mailing address:
  • Phone: 470-713-6770
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD123381
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: