Provider Demographics
NPI:1447229794
Name:WONG, SAMANTHA (DMD)
Entity Type:Individual
Prefix:DR
First Name:SAMANTHA
Middle Name:
Last Name:WONG
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 CAMELOT DR
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH MEETING
Mailing Address - State:PA
Mailing Address - Zip Code:19462-2103
Mailing Address - Country:US
Mailing Address - Phone:610-278-0009
Mailing Address - Fax:610-278-0893
Practice Address - Street 1:108 DEKALB ST
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:PA
Practice Address - Zip Code:19405-1017
Practice Address - Country:US
Practice Address - Phone:610-278-0009
Practice Address - Fax:610-278-0893
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0350111223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1511312OtherUNITED CONCORDIA NUMBER