Provider Demographics
NPI:1376702829
Name:WONG, JONATHAN W (DDS MS)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:W
Last Name:WONG
Suffix:
Gender:M
Credentials:DDS MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41 E 8TH ST APT 3206
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60605-2441
Mailing Address - Country:US
Mailing Address - Phone:773-575-1018
Mailing Address - Fax:
Practice Address - Street 1:41 E 8TH ST APT 3206
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60605-2441
Practice Address - Country:US
Practice Address - Phone:773-575-1018
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-09
Last Update Date:2008-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190276371223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice