Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0700X | Prosthodontist | DTP 409 | FL |
NPI | 1063470177 |
---|---|
Provider Name | Dr. Fong Wong |
First Address | Gainesville, FL 32610-0405 |
Second Address | Gainesville, FL 32610-3003 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 01/05/2006 |
Last Update Date | 03/04/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
V12122 | (02) | FL |