Provider Demographics
NPI:1154464790
Name:WONG, LESLIE MARK (DDS)
Entity type:Individual
Prefix:DR
First Name:LESLIE
Middle Name:MARK
Last Name:WONG
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:LES
Other - Middle Name:M
Other - Last Name:WONG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:827 BLOSSOM HILL RD
Mailing Address - Street 2:SUITE W-3
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95123-2701
Mailing Address - Country:US
Mailing Address - Phone:408-224-2000
Mailing Address - Fax:408-224-4111
Practice Address - Street 1:827 BLOSSOM HILL RD
Practice Address - Street 2:SUITE W-3
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95123-2701
Practice Address - Country:US
Practice Address - Phone:408-224-2000
Practice Address - Fax:408-224-4111
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA338791223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice