Provider Demographics
NPI:1013184498
Name:WONG, JEFFREY Y (DDS)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
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 1:200 BROWN RD STE 202
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94539-7957
Mailing Address - Country:US
Mailing Address - Phone:510-490-0591
Mailing Address - Fax:
Practice Address - Street 1:200 BROWN RD STE 202
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94539-7957
Practice Address - Country:US
Practice Address - Phone:510-490-0591
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-14
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA301311223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics