Provider Demographics
NPI:1952477788
Name:WONG, WILLIAM SAMUEL (DDS)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:SAMUEL
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 1:1137 2ND STREET
Mailing Address - Street 2:220
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90403
Mailing Address - Country:US
Mailing Address - Phone:310-451-8103
Mailing Address - Fax:310-458-1263
Practice Address - Street 1:1137 2ND STREET
Practice Address - Street 2:220
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90403
Practice Address - Country:US
Practice Address - Phone:310-451-8103
Practice Address - Fax:310-458-1263
Is Sole Proprietor?:No
Enumeration Date:2006-11-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA37955122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist