Provider Demographics
NPI:1508089335
Name:WONG, JONATHAN S (DDS)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:S
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 1:204 PIRIE RD # B
Mailing Address - Street 2:
Mailing Address - City:OJAI
Mailing Address - State:CA
Mailing Address - Zip Code:93023-3135
Mailing Address - Country:US
Mailing Address - Phone:805-640-9664
Mailing Address - Fax:
Practice Address - Street 1:1190 S VICTORIA AVE
Practice Address - Street 2:SUITE 305
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93003-6507
Practice Address - Country:US
Practice Address - Phone:805-644-9664
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-10
Last Update Date:2009-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA516751223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics