Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0221X | Pediatric Dentist | DE00009888 | WA |
NPI | 1003841347 |
---|---|
Provider Name | Dr. Alicia K Wong |
First Address | Bellevue, WA 98005-3482 |
Second Address | Bellevue, WA 98005-3482 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 12/07/2006 |
Last Update Date | 20/02/2013 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
5047436 | (05) | WA |