Provider Demographics
NPI:1114012135
Name:WONG, DIANE M (DDS)
Entity Type:Individual
Prefix:DR
First Name:DIANE
Middle Name:M
Last Name:WONG
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:150 55TH ST
Mailing Address - Street 2:NYU LUTHERAN MEDICAL CENTER - DENTAL
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11220-2508
Mailing Address - Country:US
Mailing Address - Phone:718-630-6875
Mailing Address - Fax:
Practice Address - Street 1:150 55TH ST
Practice Address - Street 2:NYU LUTHERAN MEDICAL CENTER - DENTAL
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11220-2508
Practice Address - Country:US
Practice Address - Phone:718-630-6875
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2015-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0469461223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry