Provider Demographics
NPI:1487126082
Name:MATOS WONG, ALEXANDER CARLOS (DDS)
Entity type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:CARLOS
Last Name:MATOS WONG
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15120 MAGNOLIA BOULEVARD
Mailing Address - Street 2:APARTMENT 106
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91403-1219
Mailing Address - Country:US
Mailing Address - Phone:818-326-2873
Mailing Address - Fax:818-646-0800
Practice Address - Street 1:15120 MAGNOLIA BOULEVARD
Practice Address - Street 2:APARTMENT 106
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91403-1219
Practice Address - Country:US
Practice Address - Phone:818-326-2873
Practice Address - Fax:818-646-0800
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-19
Last Update Date:2018-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1034361223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice