Active NPI
Eric Bao- Toan Wong, D.D.S.
- General Practice Dentistry
- San Rafael, CA
National Provider Identifier
1245583996
On this page
Key facts
NPPES NPI Registry- Primary specialty
- General Practice Dentistry
- License
- 61921
- Practice address
- 750 Las Gallinas Ave.
#217
San Rafael, CA 94903 - Phone
- (415) 479-2623
- NPI assigned
- Oct 18, 2012
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| General Practice Dentistry | 1223G0001X | 61921 | CA | Primary |
Addresses
Primary practice location
750 Las Gallinas Ave.
#217
San Rafael, CA 94903
Mailing address
750 Las Gallinas Ave.
#217
San Rafael, CA 94903
Phone (415) 479-2623
Other practice location 1
1400 N Riverside Ave
Rialto, CA 92376-8053
Phone (909) 875-8110
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
- Eligible to order & refer
- Part B services: Yes
- Medical equipment: Yes
- Home health: Yes
- Power mobility devices: No
- Hospice: Yes
- Opted out of Medicare
- Yes, effective Apr 6, 2016 through Apr 6, 2028
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 61921 | CA | MD | Physician Assistant |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Courtin Dental Inc | Past | Accepting new patients |
Organizations & group practices 1
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1350518400000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1680652800000",
"number": "1245583996",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "750 LAS GALLINAS AVE.",
"address_2": "#217",
"city": "SAN RAFAEL",
"state": "CA",
"postal_code": "94903",
"telephone_number": "415-479-2623"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "750 LAS GALLINAS AVE.",
"address_2": "#217",
"city": "SAN RAFAEL",
"state": "CA",
"postal_code": "94903",
"telephone_number": "415-479-2623"
}
],
"practiceLocations": [
{
"address_1": "1400 N Riverside Ave",
"address_purpose": "LOCATION",
"city": "Rialto",
"state": "CA",
"postal_code": "923768053",
"country_code": "US",
"telephone_number": "909-875-8110",
"country_name": "United States",
"address_type": "DOM"
}
],
"basic": {
"last_name": "WONG",
"first_name": "ERIC",
"middle_name": "BAO- TOAN",
"name_prefix": "Dr.",
"credential": "D.D.S.",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2012-10-18",
"last_updated": "2023-04-05",
"certification_date": "2023-04-05",
"status": "A"
},
"taxonomies": [
{
"code": "1223G0001X",
"taxonomy_group": "",
"desc": "Dentist, General Practice",
"state": "CA",
"license": "61921",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in San Rafael, CA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 5, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring; Opt Out Affidavits.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.