Provider Demographics
NPI:1770628042
Name:WONG, JUAN (DMD)
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:
Last Name:WONG
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 1:101 N PINE ISLAND RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33324-1843
Mailing Address - Country:US
Mailing Address - Phone:954-475-9455
Mailing Address - Fax:954-475-9931
Practice Address - Street 1:101 N PINE ISLAND RD
Practice Address - Street 2:SUITE 101
Practice Address - City:PLANTATION
Practice Address - State:FL
Practice Address - Zip Code:33324-1843
Practice Address - Country:US
Practice Address - Phone:954-475-9455
Practice Address - Fax:954-475-9931
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN168841223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice