Provider Demographics
NPI:1003841347
Name:WONG, ALICIA K (DMD, MPH)
Entity Type:Individual
Prefix:DR
First Name:ALICIA
Middle Name:K
Last Name:WONG
Suffix:
Gender:F
Credentials:DMD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:914 140TH AVE NE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98005-3482
Mailing Address - Country:US
Mailing Address - Phone:425-401-1147
Mailing Address - Fax:425-484-6424
Practice Address - Street 1:914 140TH AVE NE
Practice Address - Street 2:SUITE 101
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98005-3482
Practice Address - Country:US
Practice Address - Phone:425-401-1147
Practice Address - Fax:425-484-6424
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2013-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000098881223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5047436Medicaid