Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 122300000X | Dentist | 057530 | NY |
N | 122300000X | Dentist | 9559 | AZ |
Y | 1223D0004X | Dentist Anesthesiologist | 9559 | AZ |
NPI | 1942645528 |
---|---|
Provider Name | Jason Wong |
First Address | Casa Grande, AZ 85122-2023 |
Second Address | Casa Grande, AZ 85122-2023 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 08/05/2013 |
Last Update Date | 17/03/2018 |