Provider Demographics
NPI:1487742169
Name:WONG, IAN (DDS)
Entity type:Individual
Prefix:DR
First Name:IAN
Middle Name:
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 1:6624 LAGUNA BLVD.
Mailing Address - Street 2:SUITE # 114
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95758
Mailing Address - Country:US
Mailing Address - Phone:916-683-7800
Mailing Address - Fax:916-683-7802
Practice Address - Street 1:6624 LAGUNA BLVD.
Practice Address - Street 2:SUITE # 114
Practice Address - City:ELK GROVE
Practice Address - State:CA
Practice Address - Zip Code:95758
Practice Address - Country:US
Practice Address - Phone:916-683-7800
Practice Address - Fax:916-683-7802
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA39917122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist