Healthcare Provider Details

I. General information

NPI: 1265854426
Provider Name (Legal Business Name): ROGER T.L. WONG LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/07/2014
Last Update Date: 01/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 S BERETANIA ST SUITE C-117B
HONOLULU HI
96813-2208
US

IV. Provider business mailing address

50 S BERETANIA ST SUITE C-117B
HONOLULU HI
96813-2208
US

V. Phone/Fax

Practice location:
  • Phone: 808-538-6522
  • Fax: 808-538-1641
Mailing address:
  • Phone: 808-538-6522
  • Fax: 808-538-1641

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDT-2521
License Number StateHI
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDT-1290
License Number StateHI

VIII. Authorized Official

Name: NOLAN Y KIDO
Title or Position: ASSISTANT
Credential:
Phone: 808-538-6522