Provider Demographics
NPI:1386141257
Name:WONG, MONITA (DMD)
Entity type:Individual
Prefix:
First Name:MONITA
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 1:1860 ALCATRAZ AVE
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94703-2715
Mailing Address - Country:US
Mailing Address - Phone:510-280-6080
Mailing Address - Fax:
Practice Address - Street 1:1428 MAIN ST
Practice Address - Street 2:
Practice Address - City:WALPOLE
Practice Address - State:MA
Practice Address - Zip Code:02081-1729
Practice Address - Country:US
Practice Address - Phone:508-668-8008
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-09
Last Update Date:2023-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADDS1046281223G0001X
AZD0103761223G0001X
MADN18596481223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty