Provider Demographics
NPI:1083847578
Name:GONG, BECKY WAH RONG (DDS)
Entity Type:Individual
Prefix:DR
First Name:BECKY
Middle Name:WAH RONG
Last Name:GONG
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 1:10363 TORRE AVE #E
Mailing Address - Street 2:
Mailing Address - City:CUPERTINO
Mailing Address - State:CA
Mailing Address - Zip Code:95014
Mailing Address - Country:US
Mailing Address - Phone:408-252-3602
Mailing Address - Fax:
Practice Address - Street 1:10363 TORRE AVE #E
Practice Address - Street 2:
Practice Address - City:CUPERTINO
Practice Address - State:CA
Practice Address - Zip Code:95014
Practice Address - Country:US
Practice Address - Phone:408-252-3602
Practice Address - Fax:408-252-3603
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-31
Last Update Date:2018-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA586481223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics