MEDICARE: DR. STEPHANIE ML WONG DMD INC

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	DT-1605	HI

General Provider Information

NPI Number	:	1669516258
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DR. STEPHANIE ML WONG DMD INC

Provider Business Mailing Address
First Line	:	4211 WAIALAE AVE STE 204
Second Line	:
City	:	HONOLULU
State	:	HI
Zip	:	96816-5312
Country	:	US
Telephone Number	:	808-732-3072
Fax Number	:	808-732-0779

Provider Business Practice Location Address
First Line	:	4211 WAIALAE AVE STE 204
Second Line	:
City	:	HONOLULU
State	:	HI
Zip	:	96816-5312
Country	:	US
Telephone Number	:	808-732-3072
Fax Number	:	808-732-0779

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. STEPHANIE ML WONG
Credential	:	DMD
Telephone Number	:	808-732-3072

Provider Enumeration Date	:	02/16/2007
Last Update Date	:	08/22/2020

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