Provider Demographics
NPI:1518319938
Name:WONG, MICHELLE B (DDS)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:B
Last Name:WONG
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 E N ST
Mailing Address - Street 2:
Mailing Address - City:BENICIA
Mailing Address - State:CA
Mailing Address - Zip Code:94510-2728
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:125 E N ST
Practice Address - Street 2:
Practice Address - City:BENICIA
Practice Address - State:CA
Practice Address - Zip Code:94510-2728
Practice Address - Country:US
Practice Address - Phone:707-745-0636
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-09
Last Update Date:2016-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA52827122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist