Provider Demographics
NPI:1063637262
Name:GONG, THOMAS EUGENE (DDS)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:EUGENE
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 1:533 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RIO VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:94571-1618
Mailing Address - Country:US
Mailing Address - Phone:707-374-4321
Mailing Address - Fax:
Practice Address - Street 1:533 MAIN ST
Practice Address - Street 2:
Practice Address - City:RIO VISTA
Practice Address - State:CA
Practice Address - Zip Code:94571-1618
Practice Address - Country:US
Practice Address - Phone:707-374-4321
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA33461122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist