Provider Demographics
NPI:1144387895
Name:WONG, ANGELIC FORTUNATO (DDS)
Entity Type:Individual
Prefix:DR
First Name:ANGELIC
Middle Name:FORTUNATO
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 1:1961 MORRIS AVE STE B1
Mailing Address - Street 2:
Mailing Address - City:UNION
Mailing Address - State:NJ
Mailing Address - Zip Code:07083-3519
Mailing Address - Country:US
Mailing Address - Phone:908-688-3883
Mailing Address - Fax:908-688-4086
Practice Address - Street 1:1961 MORRIS AVE STE B1
Practice Address - Street 2:
Practice Address - City:UNION
Practice Address - State:NJ
Practice Address - Zip Code:07083-3519
Practice Address - Country:US
Practice Address - Phone:908-688-3883
Practice Address - Fax:908-688-4086
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI01744800122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist