Provider Demographics
NPI:1407476484
Name:BAJWA WONG PLLC
Entity Type:Organization
Organization Name:BAJWA WONG PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SOFIA
Authorized Official - Middle Name:
Authorized Official - Last Name:SEGURA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-901-2239
Mailing Address - Street 1:640 NW GILMAN BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:ISSAQUAH
Mailing Address - State:WA
Mailing Address - Zip Code:98027-2476
Mailing Address - Country:US
Mailing Address - Phone:425-507-2888
Mailing Address - Fax:425-507-2887
Practice Address - Street 1:640 NW GILMAN BLVD STE 100
Practice Address - Street 2:
Practice Address - City:ISSAQUAH
Practice Address - State:WA
Practice Address - Zip Code:98027-2476
Practice Address - Country:US
Practice Address - Phone:425-507-2888
Practice Address - Fax:425-507-2887
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-20
Last Update Date:2020-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty