Provider Demographics
NPI:1235823154
Name:WONG, JORDAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:JORDAN
Middle Name:
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 1:8232 TN-3 NORTH
Mailing Address - Street 2:
Mailing Address - City:MILLINGTON
Mailing Address - State:TN
Mailing Address - Zip Code:38053-5800
Mailing Address - Country:US
Mailing Address - Phone:901-872-7179
Mailing Address - Fax:
Practice Address - Street 1:8232 TN-3 NORTH
Practice Address - Street 2:
Practice Address - City:MILLINGTON
Practice Address - State:TN
Practice Address - Zip Code:38053
Practice Address - Country:US
Practice Address - Phone:901-872-7179
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-05
Last Update Date:2023-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN122181223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice