Provider Demographics
NPI:1336427384
Name:WONG, CYNTHIA LAUREL (DMD)
Entity Type:Individual
Prefix:MISS
First Name:CYNTHIA
Middle Name:LAUREL
Last Name:WONG
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 ELMWOOD AVENUE
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14620
Mailing Address - Country:US
Mailing Address - Phone:585-275-5031
Mailing Address - Fax:
Practice Address - Street 1:2400 SOUTH CLINTON AVENUE,
Practice Address - Street 2:SUITE 125
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14620
Practice Address - Country:US
Practice Address - Phone:585-341-7316
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-25
Last Update Date:2023-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY567561223P0221X
NY056756-11223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04082091Medicaid