Provider Demographics
NPI:1750590014
Name:WONG, JASON GILBERT (DDS)
Entity type:Individual
Prefix:DR
First Name:JASON
Middle Name:GILBERT
Last Name:WONG
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 1:721 W WHITTIER BLVD
Mailing Address - Street 2:STE B
Mailing Address - City:LA HABRA
Mailing Address - State:CA
Mailing Address - Zip Code:90631-3771
Mailing Address - Country:US
Mailing Address - Phone:310-463-4762
Mailing Address - Fax:
Practice Address - Street 1:721 W WHITTIER BLVD STE B
Practice Address - Street 2:
Practice Address - City:LA HABRA
Practice Address - State:CA
Practice Address - Zip Code:90631-3771
Practice Address - Country:US
Practice Address - Phone:310-463-4762
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-22
Last Update Date:2016-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA521321223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics