Provider Demographics
NPI:1073616009
Name:WONG, JEFFREY R (DDS)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:R
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 1:2844 SUMMIT ST
Mailing Address - Street 2:SUITE 105
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94609-3637
Mailing Address - Country:US
Mailing Address - Phone:510-444-7535
Mailing Address - Fax:510-444-7548
Practice Address - Street 1:2844 SUMMIT ST
Practice Address - Street 2:SUITE 105
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-3637
Practice Address - Country:US
Practice Address - Phone:510-444-7535
Practice Address - Fax:510-444-7548
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-06
Last Update Date:2017-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA36855122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist