=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962595157
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JEFF WONG, DDS, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/02/2006
-----------------------------------------------------
Last Update Date | 06/03/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 22032 EL PASEO STE. 240
-----------------------------------------------------
City | RANCHO SANTA MARGARITA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92688-3947
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-766-2786
-----------------------------------------------------
Fax | 949-766-7723
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2860 MICHELLE 2ND FLOOR
-----------------------------------------------------
City | IRVINE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92606-1009
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-508-3600
-----------------------------------------------------
Fax | 714-368-2092
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER DDS
-----------------------------------------------------
Name | DR. JEFFREY WONG
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 949-766-2786
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------