Provider Demographics
NPI:1114201555
Name:WONG, JOHN W
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:W
Last Name:WONG
Suffix:
Gender:M
Credentials:
Other - Prefix:DR
Other - First Name:JOHN
Other - Middle Name:W
Other - Last Name:WONG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMD
Mailing Address - Street 1:3151 S WHITE RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95148-4045
Mailing Address - Country:US
Mailing Address - Phone:408-945-9911
Mailing Address - Fax:
Practice Address - Street 1:3151 S WHITE RD
Practice Address - Street 2:SUITE 201
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95148-4045
Practice Address - Country:US
Practice Address - Phone:408-945-9911
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-04
Last Update Date:2011-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA28111122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist