Provider Demographics
NPI:1962616235
Name:WONG, JACQUELINE (DMD, MMSC)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:WONG
Suffix:
Gender:F
Credentials:DMD, MMSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1998 BROADWAY
Mailing Address - Street 2:APT 1207
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94109-2281
Mailing Address - Country:US
Mailing Address - Phone:415-317-6430
Mailing Address - Fax:415-346-8698
Practice Address - Street 1:1998 BROADWAY
Practice Address - Street 2:APT 1207
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94109-2281
Practice Address - Country:US
Practice Address - Phone:415-317-6430
Practice Address - Fax:415-346-8698
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA534901223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics