Healthcare Provider Details

I. General information

NPI: 1659432003
Provider Name (Legal Business Name): GERALD H B WONG DMD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/12/2006
Last Update Date: 01/14/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

41-1537 KALANIANAOLE HWY SUITE 10-B
WAIMANALO HI
96795-1185
US

IV. Provider business mailing address

41-1537 KALANIANAOLE HWY SUITE 10-B
WAIMANALO HI
96795-1185
US

V. Phone/Fax

Practice location:
  • Phone: 808-259-9454
  • Fax: 808-259-5714
Mailing address:
  • Phone: 808-259-9454
  • Fax: 808-259-5714

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberPCD 88
License Number StateHI

VIII. Authorized Official

Name: DR. GERALD H B WONG
Title or Position: PRESIDENT
Credential: DMD INC
Phone: 808-259-9454