MEDICARE: DR. JONATHAN D 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	1223G0001X	General Practice Dentistry	0401005540	VA

General Provider Information

NPI Number	:	1255490215
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JONATHAN D WONG DDS

Provider Business Mailing Address
First Line	:	1186 LYNNHAVEN PKWY
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23452-4814
Country	:	US
Telephone Number	:	757-468-4867
Fax Number	:	757-368-0797

Provider Business Practice Location Address
First Line	:	1186 LYNNHAVEN PKWY
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23452-4814
Country	:	US
Telephone Number	:	757-468-4861
Fax Number	:	757-368-0797

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

Provider Enumeration Date	:	12/06/2006
Last Update Date	:	08/20/2020

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