Provider Demographics
NPI:1548614092
Name:WONG, JASON (DMD, MS)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:
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 1:3925 W BOYNTON BEACH BLVD STE 106
Mailing Address - Street 2:
Mailing Address - City:BOYNTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33436-4500
Mailing Address - Country:US
Mailing Address - Phone:561-734-2001
Mailing Address - Fax:561-734-8234
Practice Address - Street 1:3925 W BOYNTON BEACH BLVD STE 106
Practice Address - Street 2:
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33436-4500
Practice Address - Country:US
Practice Address - Phone:561-734-2001
Practice Address - Fax:561-734-2001
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-21
Last Update Date:2022-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL256891223P0300X
TN105101223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
No1223G0001XDental ProvidersDentistGeneral Practice