Provider Demographics
NPI:1043224165
Name:GONG, KENNETH L (DDS)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:L
Last Name:GONG
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 1:1840 4TH ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LIVERMORE
Mailing Address - State:CA
Mailing Address - Zip Code:94550-4454
Mailing Address - Country:US
Mailing Address - Phone:925-960-0777
Mailing Address - Fax:
Practice Address - Street 1:1840 4TH ST
Practice Address - Street 2:SUITE 100
Practice Address - City:LIVERMORE
Practice Address - State:CA
Practice Address - Zip Code:94550-4454
Practice Address - Country:US
Practice Address - Phone:925-960-0777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA420491223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice