Provider Demographics
NPI:1063470177
Name:WONG, FONG (DDS)
Entity Type:Individual
Prefix:DR
First Name:FONG
Middle Name:
Last Name:WONG
Suffix:
Gender:F
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:PO BOX 100405
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32610-0405
Mailing Address - Country:US
Mailing Address - Phone:352-392-6474
Mailing Address - Fax:352-846-0248
Practice Address - Street 1:1600 SW ARCHER RD
Practice Address - Street 2:D4-4
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32610-3003
Practice Address - Country:US
Practice Address - Phone:352-273-5800
Practice Address - Fax:352-392-3070
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2008-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDTP 4091223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLV12122Medicare UPIN
FLAC451ZMedicare PIN