Provider Demographics
NPI:1639936172
Name:JILLIAN REYNOLDS DDS & JONATHAN L WONG DMD, A DIVISION OF ATLANTIC DEN
Entity Type:Organization
Organization Name:JILLIAN REYNOLDS DDS & JONATHAN L WONG DMD, A DIVISION OF ATLANTIC DEN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:L
Authorized Official - Last Name:WONG
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:757-963-0001
Mailing Address - Street 1:6161 KEMPSVILLE CIR STE 345
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23502-3950
Mailing Address - Country:US
Mailing Address - Phone:757-963-0001
Mailing Address - Fax:757-961-9988
Practice Address - Street 1:6161 KEMPSVILLE CIR STE 345
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23502-3950
Practice Address - Country:US
Practice Address - Phone:757-963-0001
Practice Address - Fax:757-961-9988
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ATLANTIC DENTAL CARE, PLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-03-01
Last Update Date:2024-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223D0004XDental ProvidersDentistDentist AnesthesiologistGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty