Provider Demographics
NPI:1861531428
Name:WONG, SCOTT KENDRICK (DDS)
Entity type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:KENDRICK
Last Name:WONG
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 1:848 S BERETANIA ST STE 304
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96813-2551
Mailing Address - Country:US
Mailing Address - Phone:808-531-5071
Mailing Address - Fax:
Practice Address - Street 1:848 S BERETANIA ST STE 304
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96813-2551
Practice Address - Country:US
Practice Address - Phone:808-531-5071
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI15241223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI1524OtherHDS
HI834948OtherUNITED CONCORDIA
HIA2403-2OtherHMSA
HI02171301Medicaid