Provider Demographics
NPI:1366064859
Name:SIMON WONG DDS INC
Entity type:Organization
Organization Name:SIMON WONG DDS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SIMON
Authorized Official - Middle Name:
Authorized Official - Last Name:WONG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:626-354-9667
Mailing Address - Street 1:1111 N BRAND BLVD STE B
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91202-3072
Mailing Address - Country:US
Mailing Address - Phone:818-246-4068
Mailing Address - Fax:
Practice Address - Street 1:1111 N BRAND BLVD STE B
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91202-3072
Practice Address - Country:US
Practice Address - Phone:818-246-4068
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-07
Last Update Date:2020-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental