Provider Demographics
NPI:1376539429
Name:WONG, WILSON (DDS)
Entity Type:Individual
Prefix:DR
First Name:WILSON
Middle Name:
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 1:2340 IRVING ST
Mailing Address - Street 2:STE 105
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94122-1641
Mailing Address - Country:US
Mailing Address - Phone:415-753-0333
Mailing Address - Fax:
Practice Address - Street 1:2340 IRVING ST
Practice Address - Street 2:STE 105
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94122-1641
Practice Address - Country:US
Practice Address - Phone:415-753-0333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-23
Last Update Date:2008-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAB36856122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB36856Medicare ID - Type UnspecifiedDENTICAL