Provider Demographics
NPI:1578961256
Name:DEREK WONG PROFESSIONAL DENTAL CORPORATION
Entity Type:Organization
Organization Name:DEREK WONG PROFESSIONAL DENTAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:
Authorized Official - Last Name:WONG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:213-820-0351
Mailing Address - Street 1:430 S GARFIELD AVE STE 408
Mailing Address - Street 2:
Mailing Address - City:ALHAMBRA
Mailing Address - State:CA
Mailing Address - Zip Code:91801-3877
Mailing Address - Country:US
Mailing Address - Phone:626-284-6626
Mailing Address - Fax:888-574-6449
Practice Address - Street 1:430 S GARFIELD AVE STE 408
Practice Address - Street 2:
Practice Address - City:ALHAMBRA
Practice Address - State:CA
Practice Address - Zip Code:91801-3877
Practice Address - Country:US
Practice Address - Phone:626-284-6626
Practice Address - Fax:888-574-6449
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-12
Last Update Date:2014-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA581571223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty