Healthcare Provider Details

I. General information

NPI: 1184155962
Provider Name (Legal Business Name): JILLIAN REYNOLDS, DDS & JONATHAN L WONG, DMD , PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/23/2017
Last Update Date: 02/17/2024
Certification Date: 02/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6161 KEMPSVILLE CIR SUITE 345
NORFOLK VA
23502-3932
US

IV. Provider business mailing address

303 55TH ST UNIT A
VIRGINIA BEACH VA
23451-2231
US

V. Phone/Fax

Practice location:
  • Phone: 602-799-1748
  • Fax:
Mailing address:
  • Phone: 602-799-1748
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number0401414467
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number0401413751
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code1223D0004X
TaxonomyDental Anesthesiology
License Number0447000045
License Number StateVA

VIII. Authorized Official

Name: DR. JONATHAN LAWRENCE WONG
Title or Position: DENTIST ANESTHESIOLOGIST, OWNER
Credential: DMD
Phone: 602-799-1748