Provider Demographics
NPI:1114979002
Name:FONG, DAN C (DDS)
Entity Type:Individual
Prefix:
First Name:DAN
Middle Name:C
Last Name:FONG
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 1:4323 HILL ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29207-6022
Mailing Address - Country:US
Mailing Address - Phone:803-751-5221
Mailing Address - Fax:
Practice Address - Street 1:4323 HILL ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29207-6022
Practice Address - Country:US
Practice Address - Phone:803-751-5221
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2016-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA412491223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics