Provider Demographics
NPI:1811214356
Name:ERIC T. WONG D.D.S., A PROFESSIONAL CORP
Entity Type:Organization
Organization Name:ERIC T. WONG D.D.S., A PROFESSIONAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:WONG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:310-259-2114
Mailing Address - Street 1:23326 HAWTHORNE BLVD STE 310
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90505-3757
Mailing Address - Country:US
Mailing Address - Phone:310-378-4220
Mailing Address - Fax:310-378-9222
Practice Address - Street 1:23326 HAWTHORNE BLVD STE 310
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-3757
Practice Address - Country:US
Practice Address - Phone:310-378-4220
Practice Address - Fax:310-378-9222
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-23
Last Update Date:2011-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA583951223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty