Provider Demographics
NPI:1689805277
Name:WONG, CHRISTINA DIANE (DDS)
Entity Type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:DIANE
Last Name:WONG
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:925 W 34TH ST STE 151
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90089-0641
Mailing Address - Country:US
Mailing Address - Phone:213-740-7405
Mailing Address - Fax:
Practice Address - Street 1:925 W 34TH ST STE 151
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90089-0641
Practice Address - Country:US
Practice Address - Phone:213-740-7405
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-31
Last Update Date:2009-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA0360341223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice