MEDICARE: JENNIFER CECILIA 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	1223G0001X	General Practice Dentistry	52131	CA

General Provider Information

NPI Number	:	1669526182
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNIFER CECILIA WONG DDS

Provider Business Mailing Address
First Line	:	11262 WASHINGTON BLVD
Second Line	:
City	:	CULVER CITY
State	:	CA
Zip	:	90230-4616
Country	:	US
Telephone Number	:	626-354-1832
Fax Number	:	626-354-1832

Provider Business Practice Location Address
First Line	:	11262 WASHINGTON BLVD
Second Line	:
City	:	CULVER CITY
State	:	CA
Zip	:	90230-4616
Country	:	US
Telephone Number	:	626-354-1832
Fax Number	:

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

Provider Enumeration Date	:	01/22/2007
Last Update Date	:	08/31/2012

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