Provider Demographics
NPI:1184155962
Name:JILLIAN REYNOLDS, DDS & JONATHAN L WONG, DMD , PLLC
Entity type:Organization
Organization Name:JILLIAN REYNOLDS, DDS & JONATHAN L WONG, DMD , PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTIST ANESTHESIOLOGIST, OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:LAWRENCE
Authorized Official - Last Name:WONG
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:602-799-1748
Mailing Address - Street 1:303 55TH ST
Mailing Address - Street 2:UNIT A
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23451-2231
Mailing Address - Country:US
Mailing Address - Phone:602-799-1748
Mailing Address - Fax:
Practice Address - Street 1:6161 KEMPSVILLE CIR
Practice Address - Street 2:SUITE 345
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23502-3932
Practice Address - Country:US
Practice Address - Phone:602-799-1748
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-23
Last Update Date:2024-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401414467122300000X
VA04014137511223P0221X
VA04470000451223D0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223D0004XDental ProvidersDentistDental AnesthesiologyGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty