Healthcare Provider Details

I. General information

NPI: 1639936172
Provider Name (Legal Business Name): JILLIAN REYNOLDS DDS & JONATHAN L WONG DMD, A DIVISION OF ATLANTIC DEN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/01/2024
Last Update Date: 03/01/2024
Certification Date: 03/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6161 KEMPSVILLE CIR STE 345
NORFOLK VA
23502-3950
US

IV. Provider business mailing address

6161 KEMPSVILLE CIR STE 345
NORFOLK VA
23502-3950
US

V. Phone/Fax

Practice location:
  • Phone: 757-963-0001
  • Fax: 757-961-9988
Mailing address:
  • Phone: 757-963-0001
  • Fax: 757-961-9988

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223D0004X
TaxonomyDental Anesthesiology
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: DR. JONATHAN L WONG
Title or Position: MEMBER
Credential: DMD
Phone: 757-963-0001