Provider Demographics
NPI:1144222084
Name:WONG, PERRY S (DDS)
Entity Type:Individual
Prefix:DR
First Name:PERRY
Middle Name:S
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:MARIPOSA INDIAN HEALTH CLINIC
Mailing Address - Street 2:PO BOX 1569
Mailing Address - City:MARIPOSA
Mailing Address - State:CA
Mailing Address - Zip Code:95338-1569
Mailing Address - Country:US
Mailing Address - Phone:209-966-0573
Mailing Address - Fax:209-742-6321
Practice Address - Street 1:MARIPOSA INDIAN HEALTH CLINIC
Practice Address - Street 2:5192 HOSPITAL ROAD
Practice Address - City:MARIPOSA
Practice Address - State:CA
Practice Address - Zip Code:95338-1569
Practice Address - Country:US
Practice Address - Phone:209-966-0573
Practice Address - Fax:209-742-6321
Is Sole Proprietor?:No
Enumeration Date:2005-08-11
Last Update Date:2021-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA41327122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist