Provider Demographics
NPI:1811696693
Name:WONG, DERRICK
Entity type:Individual
Prefix:
First Name:DERRICK
Middle Name:
Last Name:WONG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8911 ARANSAS BAY
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-2380
Mailing Address - Country:US
Mailing Address - Phone:903-292-8131
Mailing Address - Fax:
Practice Address - Street 1:1901 BABCOCK RD STE 201
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-4546
Practice Address - Country:US
Practice Address - Phone:903-292-8131
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-01
Last Update Date:2025-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TX404311223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty