Provider Demographics
NPI:1215563622
Name:BERSABA VONG, ELAINE ABANTE (DDS)
Entity Type:Individual
Prefix:
First Name:ELAINE
Middle Name:ABANTE
Last Name:BERSABA VONG
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 1:12481 KOKOMO CT
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92392-6780
Mailing Address - Country:US
Mailing Address - Phone:775-848-1212
Mailing Address - Fax:
Practice Address - Street 1:12821 MAIN ST STE 150
Practice Address - Street 2:
Practice Address - City:HESPERIA
Practice Address - State:CA
Practice Address - Zip Code:92345-9130
Practice Address - Country:US
Practice Address - Phone:760-947-9853
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-17
Last Update Date:2020-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADDS103724122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist