1750556627 NPI number — FU WONG DDS PA

Table of content: (NPI 1750556627)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750556627 NPI number — FU WONG DDS PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FU WONG DDS PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
LAKELAND FAMILY DENTAL
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1750556627
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/23/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7200 HEMLOCK LANE N FU WONG DDS PA
Provider Second Line Business Mailing Address:
SUITE 105
Provider Business Mailing Address City Name:
MAPLE GROVE
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55369
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
763-424-4415
Provider Business Mailing Address Fax Number:
763-425-9428

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7200 HEMLOCK LANE N FU WONG DDS PA
Provider Second Line Business Practice Location Address:
SUITE 105
Provider Business Practice Location Address City Name:
MAPLE GROVE
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55369
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
763-424-4415
Provider Business Practice Location Address Fax Number:
763-425-9428
Provider Enumeration Date:
04/23/2008

Additional Information

Authorized Official

Authorized Official Last Name:
WONG
Authorized Official First Name:
FU
Authorized Official Middle Name:
KEUNG
Authorized Official Title or Position:
PRESIDENT DENTIST
Authorized Official Telephone Number:
763-424-4415

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  10739 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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