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General NPI Number Information
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NPI Number | 1144741737
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Entity Type | Individual
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Provider Name | KING CHEONG BRIAN WONG DDS
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Gender | Male
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Dates
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Enumeration Date | 07/04/2017
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Last Update Date | 09/22/2021
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Provider Practice Location Address
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Address Line | 2011 CEDAR ST
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City | FOREST GROVE
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State | OR
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Zip | 97116-1701
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Country | US
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Telephone | 503-357-5221
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Fax |
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Provider Business Mailing Address
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Address Line | 1150 NW QUIMBY ST UNIT 304
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City | PORTLAND
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State | OR
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Zip | 97209-2488
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Country | US
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Telephone | 808-728-8867
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 61440
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License Number State | KS
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Taxonomy #2
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 61440
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License Number State | KS
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Taxonomy #3
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | D10874
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License Number State | OR
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