Provider Demographics
NPI:1063877074
Name:WONG, THOMAS (DDS)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:
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 1:1131 NEWPARK MALL
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:CA
Mailing Address - Zip Code:94560-5246
Mailing Address - Country:US
Mailing Address - Phone:510-796-8888
Mailing Address - Fax:510-796-0397
Practice Address - Street 1:1131 NEWPARK MALL
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:CA
Practice Address - Zip Code:94560-5246
Practice Address - Country:US
Practice Address - Phone:510-796-8888
Practice Address - Fax:510-796-0397
Is Sole Proprietor?:No
Enumeration Date:2015-12-17
Last Update Date:2015-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA31732122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist