Provider Demographics
NPI:1205080009
Name:WONG, KAM (LD)
Entity type:Individual
Prefix:
First Name:KAM
Middle Name:
Last Name:WONG
Suffix:
Gender:M
Credentials:LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4501 44TH AVE SW
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98116-4116
Mailing Address - Country:US
Mailing Address - Phone:206-935-6844
Mailing Address - Fax:206-935-6844
Practice Address - Street 1:4501 44TH AVE SW
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98116-4116
Practice Address - Country:US
Practice Address - Phone:206-935-6844
Practice Address - Fax:206-935-6844
Is Sole Proprietor?:No
Enumeration Date:2008-11-06
Last Update Date:2008-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA25108DN32122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122400000XDental ProvidersDenturist