=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184155962
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JILLIAN REYNOLDS, DDS & JONATHAN L WONG, DMD , PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/23/2017
-----------------------------------------------------
Last Update Date | 02/17/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6161 KEMPSVILLE CIR SUITE 345
-----------------------------------------------------
City | NORFOLK
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23502-3932
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-799-1748
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 303 55TH ST UNIT A
-----------------------------------------------------
City | VIRGINIA BEACH
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23451-2231
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-799-1748
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST ANESTHESIOLOGIST, OWNER
-----------------------------------------------------
Name | DR. JONATHAN LAWRENCE WONG
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 602-799-1748
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 0401414467
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number | 0401413751
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 1223D0004X
-----------------------------------------------------
Taxonomy Name | Dental Anesthesiology
-----------------------------------------------------
License Number | 0447000045
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------