Provider Demographics
NPI:1508099938
Name:WONG, ANDREW C (DMD, MS)
Entity Type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:C
Last Name:WONG
Suffix:
Gender:M
Credentials:DMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3900 NEWPARK MALL ROAD
Mailing Address - Street 2:SUITE 204
Mailing Address - City:NEWARK
Mailing Address - State:CA
Mailing Address - Zip Code:94560-5241
Mailing Address - Country:US
Mailing Address - Phone:510-796-1793
Mailing Address - Fax:
Practice Address - Street 1:3900 NEWPARK MALL ROAD
Practice Address - Street 2:SUITE 204
Practice Address - City:NEWARK
Practice Address - State:CA
Practice Address - Zip Code:94560-5241
Practice Address - Country:US
Practice Address - Phone:510-796-1793
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-02
Last Update Date:2009-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA370381223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics