Provider Demographics
NPI:1942542162
Name:WONG, MARK (MS, DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:WONG
Suffix:
Gender:M
Credentials:MS, DDS
Other - Prefix:
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Mailing Address - Street 1:320 W BADILLO ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91723-1833
Mailing Address - Country:US
Mailing Address - Phone:626-966-3131
Mailing Address - Fax:626-966-7603
Practice Address - Street 1:320 W BADILLO ST
Practice Address - Street 2:SUITE 201
Practice Address - City:COVINA
Practice Address - State:CA
Practice Address - Zip Code:91723-1833
Practice Address - Country:US
Practice Address - Phone:626-966-3131
Practice Address - Fax:626-966-7603
Is Sole Proprietor?:No
Enumeration Date:2013-03-26
Last Update Date:2013-03-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA420211223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics