Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223D0001X | Dental Public Health | DN14802 | FL |
NPI | 1437298973 |
---|---|
Provider Name | Dr. Carol Wong |
First Address | Lake Alfred, FL 33850-2750 |
Second Address | Lake Alfred, FL 33850-2750 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 05/02/2007 |
Last Update Date | 27/04/2013 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
075405600 | (05) | FL |