Provider Demographics
NPI:1003912528
Name:FONG, KEVIN DAVID (DDS)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:DAVID
Last Name:FONG
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 1:944 W WINTON AVE
Mailing Address - Street 2:
Mailing Address - City:HAYWARD
Mailing Address - State:CA
Mailing Address - Zip Code:94545-1521
Mailing Address - Country:US
Mailing Address - Phone:510-783-1572
Mailing Address - Fax:510-259-1952
Practice Address - Street 1:944 W WINTON AVE
Practice Address - Street 2:
Practice Address - City:HAYWARD
Practice Address - State:CA
Practice Address - Zip Code:94545-1521
Practice Address - Country:US
Practice Address - Phone:510-783-1572
Practice Address - Fax:510-259-1952
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-15
Last Update Date:2008-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA41248122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist