Provider Demographics
NPI:1043646326
Name:DEREK WONG DDS, INC
Entity Type:Organization
Organization Name:DEREK WONG DDS, INC
Other - Org Name:WONG ORTHODONTICS
Other - Org Type:Other Name
Authorized Official - Title/Position:ORTHODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:
Authorized Official - Last Name:WONG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:213-820-0351
Mailing Address - Street 1:826 N MONTEREY ST
Mailing Address - Street 2:UNIT A
Mailing Address - City:ALHAMBRA
Mailing Address - State:CA
Mailing Address - Zip Code:91801-6425
Mailing Address - Country:US
Mailing Address - Phone:213-820-0351
Mailing Address - Fax:
Practice Address - Street 1:10626 PARAMOUNT BLVD
Practice Address - Street 2:
Practice Address - City:DOWNEY
Practice Address - State:CA
Practice Address - Zip Code:90241-3304
Practice Address - Country:US
Practice Address - Phone:562-861-7234
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-19
Last Update Date:2013-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA581571223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty