Basic Information
| Provider Information | |||||||||
| NPI: | 1962407833 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WONG | ||||||||
| FirstName: | ROGER | ||||||||
| MiddleName: | T. L. | ||||||||
| NamePrefix: | DR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 50 S BERETANIA ST | ||||||||
| Address2: | STE C117B | ||||||||
| City: | HONOLULU | ||||||||
| State: | HI | ||||||||
| PostalCode: | 968132287 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8085386522 | ||||||||
| FaxNumber: | 8085381641 | ||||||||
| Practice Location | |||||||||
| Address1: | 50 S BERETANIA ST | ||||||||
| Address2: | STE C117B | ||||||||
| City: | HONOLULU | ||||||||
| State: | HI | ||||||||
| PostalCode: | 968132287 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8085386522 | ||||||||
| FaxNumber: | 8085381641 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 1290 | HI | Y | Dental Providers | Dentist | General Practice |
No ID Information.