MEDICARE: DR. BENSON H WONG D.D.S.

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	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	41326	CA

General Provider Information

NPI Number	:	1881767259
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BENSON H WONG D.D.S.

Provider Business Mailing Address
First Line	:	931 SAN BRUNO AVE W RM 3
Second Line	:
City	:	SAN BRUNO
State	:	CA
Zip	:	94066-3435
Country	:	US
Telephone Number	:	650-588-7936
Fax Number	:	650-588-7938

Provider Business Practice Location Address
First Line	:	931 SAN BRUNO AVE W RM 3
Second Line	:
City	:	SAN BRUNO
State	:	CA
Zip	:	94066-3435
Country	:	US
Telephone Number	:	650-588-7936
Fax Number	:	650-588-7938

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

Provider Enumeration Date	:	11/15/2006
Last Update Date	:	07/08/2007

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Directions to “ DR. BENSON H WONG D.D.S.” Practice Location

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