Provider Demographics
NPI:1497988232
Name:WONG, KENNETH D (DDS)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:D
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 1:13197 CENTRAL AVE. STE 103
Mailing Address - Street 2:
Mailing Address - City:CHINO
Mailing Address - State:CA
Mailing Address - Zip Code:91710-4178
Mailing Address - Country:US
Mailing Address - Phone:909-627-8501
Mailing Address - Fax:909-627-1784
Practice Address - Street 1:13197 CENTRAL AVE STE 103
Practice Address - Street 2:
Practice Address - City:CHINO
Practice Address - State:CA
Practice Address - Zip Code:91710-4178
Practice Address - Country:US
Practice Address - Phone:909-627-8501
Practice Address - Fax:909-627-1784
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-27
Last Update Date:2024-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA403241223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice