Provider Demographics
NPI:1710308507
Name:WON, ANDREW JAY (DMD)
Entity Type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:JAY
Last Name:WON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1759 SUNNYPARK
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92374-5578
Mailing Address - Country:US
Mailing Address - Phone:909-286-5758
Mailing Address - Fax:
Practice Address - Street 1:1759 SUNNYPARK
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92374-5578
Practice Address - Country:US
Practice Address - Phone:909-286-5758
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-20
Last Update Date:2013-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA63150122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist