Provider Demographics
NPI:1972120335
Name:WONG, SARAH NICOLE (DDS)
Entity Type:Individual
Prefix:DR
First Name:SARAH
Middle Name:NICOLE
Last Name:WONG
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44405 WOODWARD AVENUE
Mailing Address - Street 2:MEDICAL EDUCATION - H23
Mailing Address - City:PONTIAC
Mailing Address - State:MI
Mailing Address - Zip Code:48341
Mailing Address - Country:US
Mailing Address - Phone:313-917-3391
Mailing Address - Fax:
Practice Address - Street 1:44405 WOODWARD AVENUE
Practice Address - Street 2:MEDICAL EDUCATION - H23
Practice Address - City:PONTIAC
Practice Address - State:MI
Practice Address - Zip Code:48341
Practice Address - Country:US
Practice Address - Phone:313-917-3391
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-01
Last Update Date:2020-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29510008171223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice