Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223E0200X | Endodontist | 12257 | TX |
NPI | 1003929654 |
---|---|
Provider Name | Dr. Kenneth Paul Wong |
First Address | Dallas, TX 75225-6203 |
Second Address | Dallas, TX 75225-6203 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 17/08/2006 |
Last Update Date | 08/07/2007 |