Provider Demographics
NPI:1639282569
Name:WONG, NELSON JO (DDS)
Entity Type:Individual
Prefix:DR
First Name:NELSON
Middle Name:JO
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 1:1510 DEL WEBB BLVD
Mailing Address - Street 2:B106
Mailing Address - City:LINCOLN
Mailing Address - State:CA
Mailing Address - Zip Code:95648-7802
Mailing Address - Country:US
Mailing Address - Phone:916-408-2273
Mailing Address - Fax:916-543-9368
Practice Address - Street 1:1510 DEL WEBB BLVD
Practice Address - Street 2:B106
Practice Address - City:LINCOLN
Practice Address - State:CA
Practice Address - Zip Code:95648-7802
Practice Address - Country:US
Practice Address - Phone:916-408-2273
Practice Address - Fax:916-543-9368
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA37756122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist