Provider Demographics
NPI:1700154200
Name:WAMBA, JON MONTGOMERY (DDS)
Entity Type:Individual
Prefix:DR
First Name:JON
Middle Name:MONTGOMERY
Last Name:WAMBA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1602 E HERITAGE LN
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99208-8509
Mailing Address - Country:US
Mailing Address - Phone:509-468-0677
Mailing Address - Fax:
Practice Address - Street 1:1602 E HERITAGE LN
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99208-8509
Practice Address - Country:US
Practice Address - Phone:509-468-0677
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-12
Last Update Date:2011-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE 000030731223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice