MEDICARE: ALLEN M.O. 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	1223	HI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1223	OTHER	HI	HAWAII DENTAL SERVICE
2	000851997	OTHER	HI	HAWAII MEDICAL SERVICE ASSOCIATION

General Provider Information

NPI Number	:	1841542388
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ALLEN M.O. WONG, DDS

Provider Business Mailing Address
First Line	:	1300 PALI HWY
Second Line	:	SUITE 211
City	:	HONOLULU
State	:	HI
Zip	:	96813-2206
Country	:	US
Telephone Number	:	808-538-1076
Fax Number	:	808-538-1076

Provider Business Practice Location Address
First Line	:	1300 PALI HWY
Second Line	:	SUITE 211
City	:	HONOLULU
State	:	HI
Zip	:	96813-2206
Country	:	US
Telephone Number	:	808-538-1076
Fax Number	:	808-538-1076

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MR. GARY MARN KEONG WONG
Credential	:	M.B.A.
Telephone Number	:	808-538-7279

Provider Enumeration Date	:	10/08/2012
Last Update Date	:	10/09/2012

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