Provider Demographics
NPI:1003023268
Name:WONG, SAM Y (DDS)
Entity Type:Individual
Prefix:DR
First Name:SAM
Middle Name:Y
Last Name:WONG
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1904 FRANKLIN ST
Mailing Address - Street 2:SUITE 511
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94612-2912
Mailing Address - Country:US
Mailing Address - Phone:510-893-8066
Mailing Address - Fax:510-893-6542
Practice Address - Street 1:1904 FRANKLIN ST
Practice Address - Street 2:SUITE 511
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94612-2912
Practice Address - Country:US
Practice Address - Phone:510-893-8066
Practice Address - Fax:510-893-6542
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA24696122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist