Provider Demographics
NPI:1093179665
Name:WONG, KATHERINE A (DDS)
Entity Type:Individual
Prefix:DR
First Name:KATHERINE
Middle Name:A
Last Name:WONG
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12799 TEXANA ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92129-3616
Mailing Address - Country:US
Mailing Address - Phone:858-472-2716
Mailing Address - Fax:
Practice Address - Street 1:11008 VALLEY MALL
Practice Address - Street 2:SUITE 203
Practice Address - City:EL MONTE
Practice Address - State:CA
Practice Address - Zip Code:91731-2645
Practice Address - Country:US
Practice Address - Phone:844-757-9799
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-11
Last Update Date:2016-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA633411223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics