Provider Demographics
NPI:1336277870
Name:WONG, DERRICK B (DMD)
Entity Type:Individual
Prefix:
First Name:DERRICK
Middle Name:B
Last Name:WONG
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 E OCEAN AVE
Mailing Address - Street 2:SUITE 5
Mailing Address - City:LOMPOC
Mailing Address - State:CA
Mailing Address - Zip Code:93436-7076
Mailing Address - Country:US
Mailing Address - Phone:805-735-9200
Mailing Address - Fax:805-735-9550
Practice Address - Street 1:1111 E OCEAN AVE
Practice Address - Street 2:SUITE 5
Practice Address - City:LOMPOC
Practice Address - State:CA
Practice Address - Zip Code:93436-7076
Practice Address - Country:US
Practice Address - Phone:805-735-9200
Practice Address - Fax:805-735-9550
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA474331223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics