Healthcare Provider Details

I. General information

NPI: 1225266430
Provider Name (Legal Business Name): JONATHAN L WONG D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2009
Last Update Date: 07/21/2022
Certification Date: 07/14/2020
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 Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number0401414467
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code1223D0004X
TaxonomyDental Anesthesiology
License Number0447000045
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: