Provider Demographics
NPI:1174603906
Name:WONG, MARTIN DAVID (DMD)
Entity type:Individual
Prefix:DR
First Name:MARTIN
Middle Name:DAVID
Last Name:WONG
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2970 HILLTOP MALL RD
Mailing Address - Street 2:SUITE 212
Mailing Address - City:RICHMOND
Mailing Address - State:CA
Mailing Address - Zip Code:94806-1947
Mailing Address - Country:US
Mailing Address - Phone:510-222-4178
Mailing Address - Fax:510-222-8677
Practice Address - Street 1:2970 HILLTOP MALL RD
Practice Address - Street 2:SUITE 212
Practice Address - City:RICHMOND
Practice Address - State:CA
Practice Address - Zip Code:94806-1947
Practice Address - Country:US
Practice Address - Phone:510-222-4178
Practice Address - Fax:510-222-8677
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA0347981223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice