Provider Demographics
NPI:1376683425
Name:WONG, KENNETH (DDS)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
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 1:13575 W INDIAN SCHOOL RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:LITCHFIELD PARK
Mailing Address - State:AZ
Mailing Address - Zip Code:85340-4901
Mailing Address - Country:US
Mailing Address - Phone:623-536-7789
Mailing Address - Fax:623-536-4743
Practice Address - Street 1:13575 W INDIAN SCHOOL RD
Practice Address - Street 2:SUITE 300
Practice Address - City:LITCHFIELD PARK
Practice Address - State:AZ
Practice Address - Zip Code:85340-4901
Practice Address - Country:US
Practice Address - Phone:623-536-7789
Practice Address - Fax:623-536-4743
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2007-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ6346122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZD6346Medicaid