Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0221X | Pediatric Dentist | 26344 | TX |
NPI | 1073506960 |
---|---|
Provider Name | Lolo Wong |
First Address | Mckinney, TX 75071-7504 |
Second Address | Dallas, TX 75246-2013 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 25/08/2005 |
Last Update Date | 25/05/2016 |