Provider Demographics
NPI:1679508493
Name:WONG, CAROL (DDS, MS)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:
Last Name:WONG
Suffix:
Gender:F
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 1:401 GREGORY LN
Mailing Address - Street 2:SUITE 130
Mailing Address - City:PLEASANT HILL
Mailing Address - State:CA
Mailing Address - Zip Code:94523-2800
Mailing Address - Country:US
Mailing Address - Phone:925-681-1801
Mailing Address - Fax:925-681-1802
Practice Address - Street 1:401 GREGORY LN
Practice Address - Street 2:SUITE 130
Practice Address - City:PLEASANT HILL
Practice Address - State:CA
Practice Address - Zip Code:94523-2800
Practice Address - Country:US
Practice Address - Phone:925-681-1801
Practice Address - Fax:925-681-1802
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA393531223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics