Provider Demographics
NPI:1285671230
Name:WONG, SOUN L (DMD)
Entity Type:Individual
Prefix:
First Name:SOUN
Middle Name:L
Last Name:WONG
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 DELAWARE AVE
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN HILL
Mailing Address - State:PA
Mailing Address - Zip Code:18015-1105
Mailing Address - Country:US
Mailing Address - Phone:610-868-6768
Mailing Address - Fax:610-868-9078
Practice Address - Street 1:601 DELAWARE AVE
Practice Address - Street 2:
Practice Address - City:FOUNTAIN HILL
Practice Address - State:PA
Practice Address - Zip Code:18015-1105
Practice Address - Country:US
Practice Address - Phone:610-868-6768
Practice Address - Fax:610-868-9078
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS 031198 L1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice