Provider Demographics
NPI:1619136207
Name:WONG, PERRY T (DDS)
Entity Type:Individual
Prefix:
First Name:PERRY
Middle Name:T
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 1:1990 WESTWOOD BLVD
Mailing Address - Street 2:#238
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025
Mailing Address - Country:US
Mailing Address - Phone:310-474-6802
Mailing Address - Fax:310-474-7944
Practice Address - Street 1:1990 WESTWOOD BLVD
Practice Address - Street 2:#238
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025
Practice Address - Country:US
Practice Address - Phone:310-474-6802
Practice Address - Fax:310-474-7944
Is Sole Proprietor?:No
Enumeration Date:2008-06-09
Last Update Date:2008-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA360361223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice