Provider Demographics
NPI:1316535065
Name:WONG, MELANIE
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:
Last Name:WONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6871 VALLEY CIRCLE BLVD UNIT 3
Mailing Address - Street 2:
Mailing Address - City:WEST HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91307-2868
Mailing Address - Country:US
Mailing Address - Phone:818-212-4805
Mailing Address - Fax:
Practice Address - Street 1:6871 VALLEY CIRCLE BLVD UNIT 3
Practice Address - Street 2:
Practice Address - City:WEST HILLS
Practice Address - State:CA
Practice Address - Zip Code:91307-2868
Practice Address - Country:US
Practice Address - Phone:818-212-4805
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-08
Last Update Date:2021-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA802124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist