Provider Demographics
NPI:1710486865
Name:WONG, CHLOE A (DMD)
Entity Type:Individual
Prefix:
First Name:CHLOE
Middle Name:A
Last Name:WONG
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:651 S LIMESTONE ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45505-1965
Mailing Address - Country:US
Mailing Address - Phone:937-328-7262
Mailing Address - Fax:937-525-4542
Practice Address - Street 1:651 S LIMESTONE ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45505-1965
Practice Address - Country:US
Practice Address - Phone:937-328-7262
Practice Address - Fax:937-525-4542
Is Sole Proprietor?:No
Enumeration Date:2018-02-05
Last Update Date:2022-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30.025690122300000X, 1223G0001X, 1223S0112X, 1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0341833Medicaid