MEDICARE: ELITE DENTAL ASSOCIATES, PLLC

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	261QD0000X	Dental Clinic/Center	26315	TX

General Provider Information

NPI Number	:	1639542855
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ELITE DENTAL ASSOCIATES, PLLC

Provider Business Mailing Address
First Line	:	7417 WELLCREST DR
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75230-4235
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5815 LIVE OAK ST
Second Line	:	SUITE 103
City	:	DALLAS
State	:	TX
Zip	:	75214-7310
Country	:	US
Telephone Number	:	814-571-3806
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. LAWRENCE WONG
Credential	:	DMD
Telephone Number	:	814-571-3806

Provider Enumeration Date	:	11/10/2015
Last Update Date	:	11/10/2015

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