Provider Demographics
NPI:1053456822
Name:WONG, BRIAN RUSSELL (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:RUSSELL
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 1:233 W BADILLO ST STE C
Mailing Address - Street 2:
Mailing Address - City:COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91723-1966
Mailing Address - Country:US
Mailing Address - Phone:626-332-5911
Mailing Address - Fax:
Practice Address - Street 1:233 W BADILLO ST STE C
Practice Address - Street 2:
Practice Address - City:COVINA
Practice Address - State:CA
Practice Address - Zip Code:91723-1966
Practice Address - Country:US
Practice Address - Phone:626-332-5911
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-20
Last Update Date:2014-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA39577122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist