Provider Demographics
NPI:1942340583
Name:WONG, JOHNNY CHUNKAU
Entity Type:Individual
Prefix:DR
First Name:JOHNNY
Middle Name:CHUNKAU
Last Name:WONG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21731 REGAL WAY
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:CA
Mailing Address - Zip Code:92630-6033
Mailing Address - Country:US
Mailing Address - Phone:949-310-8388
Mailing Address - Fax:
Practice Address - Street 1:181 E 18TH ST
Practice Address - Street 2:SUITE NUMBER D
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92627-3069
Practice Address - Country:US
Practice Address - Phone:949-548-3384
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA45793122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist