Basic Information
Provider Information
NPI: 1063820736
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: WONG
FirstName: TRISTAN
MiddleName: S
NamePrefix:  
NameSuffix:  
Credential: D.M.D.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 6950 NE CAMPUS WAY
Address2:  
City: HILLSBORO
State: OR
PostalCode: 971245611
CountryCode: US
TelephoneNumber: 5419284300
FaxNumber:  
Practice Location
Address1: 2225 PACIFIC BLVD SE
Address2: SUITE 201
City: ALBANY
State: OR
PostalCode: 973217907
CountryCode: US
TelephoneNumber: 5419284300
FaxNumber:  
Other Information
ProviderEnumerationDate: 07/25/2014
LastUpdateDate: 05/18/2015
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
122300000XD10085ORY Dental ProvidersDentist 

No ID Information.


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