MEDICARE: DR. KING CHEONG BRIAN WONG DDS

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	122300000X	Dentist	61440	KS
2	1223G0001X	General Practice Dentistry	61440	KS
3	1223G0001X	General Practice Dentistry	D10874	OR

General Provider Information

NPI Number	:	1144741737
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KING CHEONG BRIAN WONG DDS

Provider Business Mailing Address
First Line	:	1150 NW QUIMBY ST UNIT 304
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97209-2488
Country	:	US
Telephone Number	:	808-728-8867
Fax Number	:

Provider Business Practice Location Address
First Line	:	2011 CEDAR ST
Second Line	:
City	:	FOREST GROVE
State	:	OR
Zip	:	97116-1701
Country	:	US
Telephone Number	:	503-357-5221
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/04/2017
Last Update Date	:	09/22/2021

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