Provider Demographics
NPI:1679703508
Name:WONG, AMY (DDS)
Entity Type:Individual
Prefix:DR
First Name:AMY
Middle Name:
Last Name:WONG
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:AMY
Other - Middle Name:
Other - Last Name:LIU
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:5610 W TALAVI BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85306-1881
Mailing Address - Country:US
Mailing Address - Phone:602-896-8886
Mailing Address - Fax:602-896-8885
Practice Address - Street 1:5610 W TALAVI BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85306-1881
Practice Address - Country:US
Practice Address - Phone:602-896-8886
Practice Address - Fax:602-896-8885
Is Sole Proprietor?:No
Enumeration Date:2009-07-27
Last Update Date:2009-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ38331223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice