MEDICARE: AMY WONG D.D.S., INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	305S00000X	Point of Service	56140	CA

General Provider Information

NPI Number	:	1063734036
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AMY WONG D.D.S., INC

Provider Business Mailing Address
First Line	:	1404 S SAN GABRIEL BLVD STE A
Second Line	:
City	:	SAN GABRIEL
State	:	CA
Zip	:	91776-3603
Country	:	US
Telephone Number	:	626-863-8578
Fax Number	:

Provider Business Practice Location Address
First Line	:	1404 S SAN GABRIEL BLVD STE A
Second Line	:
City	:	SAN GABRIEL
State	:	CA
Zip	:	91776-3603
Country	:	US
Telephone Number	:	626-863-8578
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. AMY WONG
Credential	:	D.D.S.
Telephone Number	:	626-863-8575

Provider Enumeration Date	:	02/18/2010
Last Update Date	:	11/02/2011

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