MEDICARE: DR. FU 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	10739	MN

General Provider Information

NPI Number	:	1801885991
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. FU WONG DDS

Provider Business Mailing Address
First Line	:	4600 COVEY TRL
Second Line	:
City	:	MEDINA
State	:	MN
Zip	:	55340-4000
Country	:	US
Telephone Number	:	763-424-4415
Fax Number	:

Provider Business Practice Location Address
First Line	:	7200 HEMLOCK LN N
Second Line	:	SUITE 105
City	:	MAPLE GROVE
State	:	MN
Zip	:	55369-5576
Country	:	US
Telephone Number	:	763-424-4415
Fax Number	:	763-425-9428

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

Provider Enumeration Date	:	10/20/2005
Last Update Date	:	06/11/2008

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