Provider Demographics
NPI:1316048689
Name:WONG, CHUNG KWANG RAYMOND (DDS, MSD)
Entity type:Individual
Prefix:
First Name:CHUNG KWANG
Middle Name:RAYMOND
Last Name:WONG
Suffix:
Gender:F
Credentials:DDS, MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6920 PARKDALE PL
Mailing Address - Street 2:SUITE 217
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46254-5612
Mailing Address - Country:US
Mailing Address - Phone:317-328-6708
Mailing Address - Fax:317-328-6888
Practice Address - Street 1:6920 PARKDALE PL
Practice Address - Street 2:SUITE 217
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46254-5612
Practice Address - Country:US
Practice Address - Phone:317-328-6708
Practice Address - Fax:317-328-6888
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120093811223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN12009381AMedicaid