Provider Demographics
NPI:1447372354
Name:WONG, FRED C (DDS)
Entity type:Individual
Prefix:DR
First Name:FRED
Middle Name:C
Last Name: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 1:931 CALLE HERMOSA
Mailing Address - Street 2:
Mailing Address - City:SAN DIMAS
Mailing Address - State:CA
Mailing Address - Zip Code:91773
Mailing Address - Country:US
Mailing Address - Phone:909-394-5728
Mailing Address - Fax:
Practice Address - Street 1:408 W BASELINE RD
Practice Address - Street 2:
Practice Address - City:GLENDORA
Practice Address - State:CA
Practice Address - Zip Code:91740-4801
Practice Address - Country:US
Practice Address - Phone:626-852-6999
Practice Address - Fax:626-852-6909
Is Sole Proprietor?:No
Enumeration Date:2007-04-04
Last Update Date:2013-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA36208122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist