Provider Demographics
NPI:1417315490
Name:WONG, JACQUELINE J (DDS, MSD)
Entity type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:J
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 1:8230 NE 124TH PL
Mailing Address - Street 2:
Mailing Address - City:KIRKLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98034-2572
Mailing Address - Country:US
Mailing Address - Phone:253-234-4203
Mailing Address - Fax:
Practice Address - Street 1:1959 NE PACIFIC ST
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98195-3926
Practice Address - Country:US
Practice Address - Phone:206-685-2937
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-04
Last Update Date:2024-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARR 60576274122300000X
WADE60657443125Q00000X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentist
No125Q00000XDental ProvidersDentistOral MedicineGroup - Single Specialty