Provider Demographics
NPI:1558577866
Name:WONG, RICKEY J (DDS)
Entity Type:Individual
Prefix:DR
First Name:RICKEY
Middle Name:J
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 1:1300 BANCROFT AVE
Mailing Address - Street 2:STE. 101
Mailing Address - City:SAN LEANDRO
Mailing Address - State:CA
Mailing Address - Zip Code:94577-5147
Mailing Address - Country:US
Mailing Address - Phone:510-483-2616
Mailing Address - Fax:
Practice Address - Street 1:1300 BANCROFT AVE
Practice Address - Street 2:STE. 101
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94577-5147
Practice Address - Country:US
Practice Address - Phone:510-483-2616
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA347991223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice