Provider Demographics
NPI:1629326962
Name:WONG, KEITH B (DDS, MS)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:B
Last Name:WONG
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1818 E MERCER ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98112-4687
Mailing Address - Country:US
Mailing Address - Phone:206-812-4494
Mailing Address - Fax:206-812-4490
Practice Address - Street 1:1818 E MERCER ST
Practice Address - Street 2:SUITE 200
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98112-4687
Practice Address - Country:US
Practice Address - Phone:206-812-4494
Practice Address - Fax:206-812-4490
Is Sole Proprietor?:No
Enumeration Date:2012-08-16
Last Update Date:2012-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE602623261223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics