Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223E0200X | Endodontist | 64216 | CA |
NPI | 1154688901 |
---|---|
Provider Name | Justin Wong |
First Address | North Hills, CA 91343-2036 |
Second Address | North Hills, CA 91343 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 18/04/2012 |
Last Update Date | 26/07/2018 |