MEDICARE: DR. AMY 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	122300000X	Dentist	56140	CA

General Provider Information

NPI Number	:	1740425677
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. AMY WONG DDS

Provider Business Mailing Address
First Line	:	1404 S SAN GABRIEL BLVD STE A
Second Line	:
City	:	SAN GABRIEL
State	:	CA
Zip	:	91776-3603
Country	:	US
Telephone Number	:	626-863-8578
Fax Number	:

Provider Business Practice Location Address
First Line	:	1404 S SAN GABRIEL BLVD STE A
Second Line	:
City	:	SAN GABRIEL
State	:	CA
Zip	:	91776-3603
Country	:	US
Telephone Number	:	626-863-8578
Fax Number	:

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

Provider Enumeration Date	:	12/05/2008
Last Update Date	:	11/02/2011

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