Provider Demographics
NPI:1336201037
Name:WONG, DENNIS ROY
Entity Type:Individual
Prefix:
First Name:DENNIS
Middle Name:ROY
Last Name:WONG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11676 E VIA SALIDA
Mailing Address - Street 2:
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85367-7263
Mailing Address - Country:US
Mailing Address - Phone:928-210-2430
Mailing Address - Fax:928-345-0790
Practice Address - Street 1:2241 S AVENUE A
Practice Address - Street 2:SUITE 1
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85364-8336
Practice Address - Country:US
Practice Address - Phone:928-783-0636
Practice Address - Fax:928-783-0054
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ33551223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice