Provider Demographics
NPI:1376532473
Name:WONG, SIMON W (DDS)
Entity Type:Individual
Prefix:
First Name:SIMON
Middle Name:W
Last Name:WONG
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 1:714 61ST STREET
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11220
Mailing Address - Country:US
Mailing Address - Phone:718-238-8200
Mailing Address - Fax:718-238-3535
Practice Address - Street 1:714 61ST STREET
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11220
Practice Address - Country:US
Practice Address - Phone:718-238-8200
Practice Address - Fax:718-238-8200
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-20
Last Update Date:2008-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0488521223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice