Provider Demographics
NPI:1407021355
Name:WONG, RANDALL EUGENE (DDS)
Entity Type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:EUGENE
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 1:1601 18TH ST NW
Mailing Address - Street 2:SUITE 3
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20009-2529
Mailing Address - Country:US
Mailing Address - Phone:202-462-1999
Mailing Address - Fax:202-462-0292
Practice Address - Street 1:1601 18TH ST NW
Practice Address - Street 2:SUITE 3
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20009-2529
Practice Address - Country:US
Practice Address - Phone:202-462-1999
Practice Address - Fax:202-462-0292
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-22
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC5623122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist