=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871691170
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TANYA WONG DDS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/20/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1078 E 25TH ST
-----------------------------------------------------
City | PATERSON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07513-1632
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-742-5827
-----------------------------------------------------
Fax | 973-742-8149
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1078 E 25TH ST
-----------------------------------------------------
City | PATERSON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07513-1632
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-742-5827
-----------------------------------------------------
Fax | 973-742-8149
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0700X
-----------------------------------------------------
Taxonomy Name | Prosthodontics
-----------------------------------------------------
License Number | DI19422
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------