MEDICARE: DR. ANGELICA PAMELA 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	1223P0221X	Pediatric Dentistry	54667	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	54667	OTHER	CA	DELTA DENTAL

General Provider Information

NPI Number	:	1609920529
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ANGELICA PAMELA WONG DDS

Provider Business Mailing Address
First Line	:	7811 BAYSINGER ST
Second Line	:
City	:	DOWNEY
State	:	CA
Zip	:	90241-2224
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	151 S MEDNIK AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90022-1606
Country	:	US
Telephone Number	:	323-263-3303
Fax Number	:	323-263-3341

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

Provider Enumeration Date	:	01/22/2007
Last Update Date	:	07/08/2007

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