Provider Demographics
NPI:1063820736
Name:WONG, TRISTAN S (DMD)
Entity Type:Individual
Prefix:
First Name:TRISTAN
Middle Name:S
Last Name:WONG
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6950 NE CAMPUS WAY
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:OR
Mailing Address - Zip Code:97124-5611
Mailing Address - Country:US
Mailing Address - Phone:541-928-4300
Mailing Address - Fax:
Practice Address - Street 1:2225 PACIFIC BLVD SE
Practice Address - Street 2:SUITE 201
Practice Address - City:ALBANY
Practice Address - State:OR
Practice Address - Zip Code:97321-7907
Practice Address - Country:US
Practice Address - Phone:541-928-4300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-25
Last Update Date:2015-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD10085122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist