Provider Demographics
NPI:1689749145
Name:WONG, JUSTIN PHILLIP (DDS)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:PHILLIP
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 1:5639 E 5TH ST
Mailing Address - Street 2:STE C
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85711-2443
Mailing Address - Country:US
Mailing Address - Phone:520-745-0223
Mailing Address - Fax:520-745-2419
Practice Address - Street 1:5639 E 5TH ST
Practice Address - Street 2:STE C
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85711-2443
Practice Address - Country:US
Practice Address - Phone:520-745-0223
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ28381223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice