Provider Demographics
NPI:1285080119
Name:WONG, WINNIE (DMD)
Entity type:Individual
Prefix:
First Name:WINNIE
Middle Name:
Last Name:WONG
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42707 N RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:ELYRIA
Mailing Address - State:OH
Mailing Address - Zip Code:44035-1054
Mailing Address - Country:US
Mailing Address - Phone:440-324-3441
Mailing Address - Fax:
Practice Address - Street 1:42707 N RIDGE RD
Practice Address - Street 2:
Practice Address - City:ELYRIA
Practice Address - State:OH
Practice Address - Zip Code:44035-1054
Practice Address - Country:US
Practice Address - Phone:440-324-3441
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-10
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH300251521223G0001X
IL018.0019871223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Yes1223G0001XDental ProvidersDentistGeneral Practice