Provider Demographics
NPI:1083984942
Name:WONG, WESLEY E (DDS)
Entity Type:Individual
Prefix:
First Name:WESLEY
Middle Name:E
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 1:2720 PALAZZO CT
Mailing Address - Street 2:SUITE 201
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95356-9336
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4101 TULLY RD
Practice Address - Street 2:SUITE 201
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95356-8980
Practice Address - Country:US
Practice Address - Phone:209-577-0777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-10
Last Update Date:2012-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA45792122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist