Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | 24696 | CA |
NPI | 1003023268 |
---|---|
Provider Name | Dr. Sam Y Wong |
First Address | Oakland, CA 94612-2912 |
Second Address | Oakland, CA 94612-2912 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 17/05/2007 |
Last Update Date | 08/07/2007 |