Provider Demographics
NPI:1174650253
Name:PONG, STEPHEN Y (DDS)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:Y
Last Name:PONG
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:PO BOX 24911
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-0911
Mailing Address - Country:US
Mailing Address - Phone:206-788-3612
Mailing Address - Fax:206-652-5216
Practice Address - Street 1:780 8TH AVE S. SUITE 100
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98104-3033
Practice Address - Country:US
Practice Address - Phone:206-788-3700
Practice Address - Fax:206-788-3706
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2007-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000100691223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice