Provider Demographics
NPI:1922089325
Name:WONG, DAVID (DDS)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:
Last Name:WONG
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1527 CUSTIS CT
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30338-6986
Mailing Address - Country:US
Mailing Address - Phone:803-464-3130
Mailing Address - Fax:
Practice Address - Street 1:5805 STATE BRIDGE RD
Practice Address - Street 2:SUITE L
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30097-8220
Practice Address - Country:US
Practice Address - Phone:678-474-4917
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0128601223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice