=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023229465
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DR. HENRY C WONG
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/25/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4332 SLAUSON AVE
-----------------------------------------------------
City | MAYWOOD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90270-2848
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-771-7777
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6503 ROSEMEAD BLVD
-----------------------------------------------------
City | SAN GABRIEL
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91775-1936
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-286-2156
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 32632
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------