Provider Demographics
NPI:1841590114
Name:WONG, IRENE JOYCE (DDS)
Entity Type:Individual
Prefix:DR
First Name:IRENE
Middle Name:JOYCE
Last Name:WONG
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:IRENE
Other - Middle Name:J
Other - Last Name:WONG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:2102 N MARKET ST
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61822-1306
Mailing Address - Country:US
Mailing Address - Phone:217-351-2667
Mailing Address - Fax:
Practice Address - Street 1:2102 N MARKET ST
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61822-1306
Practice Address - Country:US
Practice Address - Phone:217-351-2667
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-02
Last Update Date:2010-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.028503122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist