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NPI Code Detail

MEDICARE: DR. ELLIS CHARLES WONG DDS

MEDICARE: DR. ELLIS CHARLES 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
11223G0001XGeneral Practice Dentistry29004CA

General Provider Information

NPI Number : 1316167711
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. ELLIS CHARLES WONG DDS
Provider Business Mailing Address
First Line : 607 N LARCHMONT BLVD
Second Line :
City : LOS ANGELES
State : CA
Zip : 90004-1307
Country : US
Telephone Number : 323-464-5555
Fax Number : 323-464-3075
Provider Business Practice Location Address
First Line : 607 N LARCHMONT BLVD
Second Line :
City : LOS ANGELES
State : CA
Zip : 90004-1307
Country : US
Telephone Number : 323-464-5555
Fax Number : 323-464-3075
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 04/26/2007
Last Update Date : 07/08/2007

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Directions to “ DR. ELLIS CHARLES WONG DDS” Practice Location

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