Provider Demographics
NPI:1316071319
Name:WONG, WAYNE L (DDS)
Entity type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:L
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 1:15651 IMPERIAL HWY
Mailing Address - Street 2:SUITE 201
Mailing Address - City:LA MIRADA
Mailing Address - State:CA
Mailing Address - Zip Code:90638-1628
Mailing Address - Country:US
Mailing Address - Phone:562-947-2555
Mailing Address - Fax:562-947-8142
Practice Address - Street 1:15651 IMPERIAL HWY
Practice Address - Street 2:SUITE 201
Practice Address - City:LA MIRADA
Practice Address - State:CA
Practice Address - Zip Code:90638-1628
Practice Address - Country:US
Practice Address - Phone:562-947-2555
Practice Address - Fax:562-947-8142
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA28831122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist