Provider Demographics
NPI:1083741938
Name:CHONG, WALLACE F III (DDS)
Entity Type:Individual
Prefix:DR
First Name:WALLACE
Middle Name:F
Last Name:CHONG
Suffix:III
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 1:74 PONAHAWAI ST
Mailing Address - Street 2:
Mailing Address - City:HILO
Mailing Address - State:HI
Mailing Address - Zip Code:96720-3026
Mailing Address - Country:US
Mailing Address - Phone:808-935-5651
Mailing Address - Fax:808-935-5551
Practice Address - Street 1:74 PONAHAWAI ST
Practice Address - Street 2:
Practice Address - City:HILO
Practice Address - State:HI
Practice Address - Zip Code:96720-3026
Practice Address - Country:US
Practice Address - Phone:808-935-5651
Practice Address - Fax:808-935-5551
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI20211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI23086-2OtherHMSA NUMBER
HI2021OtherLICENSE NUMBER
HI518087 01Medicaid