Provider Demographics
NPI:1609216928
Name:WONG, KERI ANNE JUN LAN (DDS)
Entity Type:Individual
Prefix:
First Name:KERI ANNE
Middle Name:JUN LAN
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 1:905 SPRUCE ST
Mailing Address - Street 2:STE. 300
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98104-2474
Mailing Address - Country:US
Mailing Address - Phone:206-461-6935
Mailing Address - Fax:206-461-8382
Practice Address - Street 1:6020 35TH AVE SW
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98126-3002
Practice Address - Country:US
Practice Address - Phone:206-461-6966
Practice Address - Fax:206-461-6968
Is Sole Proprietor?:No
Enumeration Date:2013-07-01
Last Update Date:2013-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARR60390607390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program