Provider Demographics
NPI:1467829887
Name:WONG, NITICHAI
Entity Type:Individual
Prefix:
First Name:NITICHAI
Middle Name:
Last Name:WONG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12219 ASHFORD MEADOWS DR
Mailing Address - Street 2:
Mailing Address - City:SUGAR LAND
Mailing Address - State:TX
Mailing Address - Zip Code:77478-6146
Mailing Address - Country:US
Mailing Address - Phone:832-293-7680
Mailing Address - Fax:
Practice Address - Street 1:14411 BELLAIRE BLVD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77083-7521
Practice Address - Country:US
Practice Address - Phone:281-575-6062
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-02
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX323211223G0001X
TX313211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice