Provider Demographics
NPI:1841311644
Name:DR TIMOTHY A WONG AND DR JOHN C FAT A PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:DR TIMOTHY A WONG AND DR JOHN C FAT A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ENDODONTIST PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:WONG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:916-427-2555
Mailing Address - Street 1:7210 S LAND PARK DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95831-3663
Mailing Address - Country:US
Mailing Address - Phone:916-427-2555
Mailing Address - Fax:916-395-2164
Practice Address - Street 1:7210 S LAND PARK DR
Practice Address - Street 2:SUITE A
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95831-3663
Practice Address - Country:US
Practice Address - Phone:916-427-2555
Practice Address - Fax:916-395-2164
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty