Provider Demographics
NPI:1841228061
Name:WONG, CRAIG WILLIAM (DMD)
Entity Type:Individual
Prefix:DR
First Name:CRAIG
Middle Name:WILLIAM
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 1:14411 NE 20TH AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98686-6431
Mailing Address - Country:US
Mailing Address - Phone:360-695-2400
Mailing Address - Fax:360-906-1116
Practice Address - Street 1:14411 NE 20TH AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98686-6431
Practice Address - Country:US
Practice Address - Phone:360-695-2400
Practice Address - Fax:360-906-1116
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAWA57741223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5049945Medicaid