Provider Demographics
NPI:1386810992
Name:WONG, JOHN C (DMD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:C
Last Name:WONG
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2080 WHITNEY AVE
Mailing Address - Street 2:SUITE 270
Mailing Address - City:HAMDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06518-3600
Mailing Address - Country:US
Mailing Address - Phone:230-248-5742
Mailing Address - Fax:
Practice Address - Street 1:2080 WHITNEY AVE
Practice Address - Street 2:SUITE 270
Practice Address - City:HAMDEN
Practice Address - State:CT
Practice Address - Zip Code:06518-3600
Practice Address - Country:US
Practice Address - Phone:230-248-5742
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-03
Last Update Date:2013-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT007829122300000X
CT78291223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No122300000XDental ProvidersDentist