Provider Demographics
NPI:1720784630
Name:WONG, SARAH ANNE (DDS, PHD)
Entity type:Individual
Prefix:DR
First Name:SARAH
Middle Name:ANNE
Last Name:WONG
Suffix:
Gender:F
Credentials:DDS, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3252 BRACKLEY DR
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48105-1181
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1011 N UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48109-1078
Practice Address - Country:US
Practice Address - Phone:734-764-1568
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-02
Last Update Date:2024-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADDS1084521223G0001X
MI29016020641223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2901602064OtherDENTAL LICENSE
CADDS108452OtherDENTAL LICENSE
MI5315247369OtherCONTROLLED SUBSTANCE LICENSE