MEDICARE: DR. AMY Y WONG D.D.S.

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	019-16908	IL

General Provider Information

NPI Number	:	1588829824
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. AMY Y WONG D.D.S.

Provider Business Mailing Address
First Line	:	310 HAPP RD
Second Line	:	SUITE 208
City	:	NORTHFIELD
State	:	IL
Zip	:	60093-3455
Country	:	US
Telephone Number	:	847-501-2882
Fax Number	:	847-501-2883

Provider Business Practice Location Address
First Line	:	310 HAPP RD
Second Line	:	SUITE 208
City	:	NORTHFIELD
State	:	IL
Zip	:	60093-3455
Country	:	US
Telephone Number	:	847-501-2882
Fax Number	:	847-501-2883

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

Provider Enumeration Date	:	07/25/2008
Last Update Date	:	07/25/2008

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