Provider Demographics
NPI:1861520249
Name:CHONG, WALLACE F JR (DDS)
Entity type:Individual
Prefix:DR
First Name:WALLACE
Middle Name:F
Last Name:CHONG
Suffix:JR
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 1:74 PONAHAWAI ST
Mailing Address - Street 2:
Mailing Address - City:HILO
Mailing Address - State:HI
Mailing Address - Zip Code:96720-3026
Mailing Address - Country:US
Mailing Address - Phone:808-935-5651
Mailing Address - Fax:808-935-5551
Practice Address - Street 1:74 PONAHAWAI ST
Practice Address - Street 2:
Practice Address - City:HILO
Practice Address - State:HI
Practice Address - Zip Code:96720-3026
Practice Address - Country:US
Practice Address - Phone:808-935-5651
Practice Address - Fax:808-935-5551
Is Sole Proprietor?:No
Enumeration Date:2007-02-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIDT-7291223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI065295-01Medicaid