Provider Demographics
NPI:1750805560
Name:WONG, MICHAEL HAROLD (DDS)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:HAROLD
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 1:2970 HILLTOP MALL RD STE 212
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:CA
Mailing Address - Zip Code:94806-1949
Mailing Address - Country:US
Mailing Address - Phone:510-222-4178
Mailing Address - Fax:
Practice Address - Street 1:2970 HILLTOP MALL RD STE 212
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:CA
Practice Address - Zip Code:94806-1949
Practice Address - Country:US
Practice Address - Phone:510-222-4178
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-02
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101751122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist