Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 122300000X | Dentist | 35568 | CA |
Y | 122300000X | Dentist | 4599 | NV |
NPI | 1003028028 |
---|---|
Provider Name | Dr. Justine Stacey Wong |
First Address | Carson City, NV 89703 |
Second Address | Carson City, NV 89703 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 03/05/2007 |
Last Update Date | 08/07/2007 |