Provider Demographics
NPI:1073770319
Name:MICHAEL J FONG, DDS, INC
Entity Type:Organization
Organization Name:MICHAEL J FONG, DDS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:FONG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:650-968-3146
Mailing Address - Street 1:2500 HOSPITAL DR
Mailing Address - Street 2:#6
Mailing Address - City:MOUNTAIN VIEW
Mailing Address - State:CA
Mailing Address - Zip Code:94040-4106
Mailing Address - Country:US
Mailing Address - Phone:650-968-3146
Mailing Address - Fax:
Practice Address - Street 1:2500 HOSPITAL DR
Practice Address - Street 2:#6
Practice Address - City:MOUNTAIN VIEW
Practice Address - State:CA
Practice Address - Zip Code:94040-4106
Practice Address - Country:US
Practice Address - Phone:650-968-3146
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-22
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA424681223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty