Provider Demographics
NPI:1144741737
Name:WONG, KING CHEONG BRIAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:KING CHEONG
Middle Name:BRIAN
Last Name:WONG
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:BRIAN
Other - Middle Name:
Other - Last Name:WONG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:1150 NW QUIMBY ST UNIT 304
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97209-2488
Mailing Address - Country:US
Mailing Address - Phone:808-728-8867
Mailing Address - Fax:
Practice Address - Street 1:2011 CEDAR ST
Practice Address - Street 2:
Practice Address - City:FOREST GROVE
Practice Address - State:OR
Practice Address - Zip Code:97116-1701
Practice Address - Country:US
Practice Address - Phone:503-357-5221
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-04
Last Update Date:2021-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS61440122300000X, 1223G0001X
ORD108741223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist