Provider Demographics
NPI:1407847254
Name:WONG, CHAD (DDS)
Entity Type:Individual
Prefix:DR
First Name:CHAD
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 1:12845 SE 93RD AVE
Mailing Address - Street 2:
Mailing Address - City:CLACKAMAS
Mailing Address - State:OR
Mailing Address - Zip Code:97015-5735
Mailing Address - Country:US
Mailing Address - Phone:503-794-1900
Mailing Address - Fax:503-794-2778
Practice Address - Street 1:12845 SE 93RD AVE
Practice Address - Street 2:
Practice Address - City:CLACKAMAS
Practice Address - State:OR
Practice Address - Zip Code:97015-5735
Practice Address - Country:US
Practice Address - Phone:503-794-1900
Practice Address - Fax:503-794-2778
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD-70861223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice