Provider Demographics
NPI:1164577458
Name:WONG, REGINA S (DDS)
Entity Type:Individual
Prefix:
First Name:REGINA
Middle Name:S
Last Name:WONG
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:REGINA
Other - Middle Name:WONG
Other - Last Name:PHILLIPS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:636 S EREMLAND DR
Mailing Address - Street 2:
Mailing Address - City:COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91723-3523
Mailing Address - Country:US
Mailing Address - Phone:626-339-7277
Mailing Address - Fax:
Practice Address - Street 1:636 S EREMLAND DR
Practice Address - Street 2:
Practice Address - City:COVINA
Practice Address - State:CA
Practice Address - Zip Code:91723-3523
Practice Address - Country:US
Practice Address - Phone:626-339-7277
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA0363031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice