Provider Demographics
NPI:1942645528
Name:WONG, JASON (DDS)
Entity Type:Individual
Prefix:
First Name:JASON
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 1:4422 N 75TH ST UNIT 6008
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85251-4080
Mailing Address - Country:US
Mailing Address - Phone:347-768-9224
Mailing Address - Fax:
Practice Address - Street 1:3101 W INDIAN SCHOOL RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85017-4035
Practice Address - Country:US
Practice Address - Phone:602-861-3333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-08
Last Update Date:2023-10-01
Deactivation Date:2014-03-27
Deactivation Code:
Reactivation Date:2016-11-18
Provider Licenses
StateLicense IDTaxonomies
NY057530122300000X
AZ9559122300000X, 1223D0004X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223D0004XDental ProvidersDentistDentist Anesthesiologist
No122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program