Provider Demographics
NPI:1548810716
Name:CECCHINI, GARRETT WAY WONG (DDS)
Entity type:Individual
Prefix:MR
First Name:GARRETT
Middle Name:WAY WONG
Last Name:CECCHINI
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 1:415 W BEVERLY BLVD
Mailing Address - Street 2:
Mailing Address - City:MONTEBELLO
Mailing Address - State:CA
Mailing Address - Zip Code:90640-3667
Mailing Address - Country:US
Mailing Address - Phone:323-722-5000
Mailing Address - Fax:
Practice Address - Street 1:415 W BEVERLY BLVD
Practice Address - Street 2:
Practice Address - City:MONTEBELLO
Practice Address - State:CA
Practice Address - Zip Code:90640-3667
Practice Address - Country:US
Practice Address - Phone:323-722-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-18
Last Update Date:2024-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADDS1102001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARDH32822Medicaid