Provider Demographics
NPI:1700187119
Name:WONG, GARRICK FREDRICK (DMD, MMS)
Entity Type:Individual
Prefix:DR
First Name:GARRICK
Middle Name:FREDRICK
Last Name:WONG
Suffix:
Gender:M
Credentials:DMD, MMS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:453 E PUTNAM AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:COS COB
Mailing Address - State:CT
Mailing Address - Zip Code:06807-2546
Mailing Address - Country:US
Mailing Address - Phone:203-622-9197
Mailing Address - Fax:
Practice Address - Street 1:453 E PUTNAM AVE STE 2
Practice Address - Street 2:
Practice Address - City:COS COB
Practice Address - State:CT
Practice Address - Zip Code:06807-2546
Practice Address - Country:US
Practice Address - Phone:203-625-9888
Practice Address - Fax:203-625-9889
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-16
Last Update Date:2019-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0074761223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics