Provider Demographics
NPI:1235385493
Name:FONG, JENNIFER MELISSA (DDS)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:MELISSA
Last Name:FONG
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 1:333 GELLERT BLVD
Mailing Address - Street 2:SUITE #242
Mailing Address - City:DALY CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94015-2621
Mailing Address - Country:US
Mailing Address - Phone:650-757-3636
Mailing Address - Fax:
Practice Address - Street 1:333 GELLERT BLVD
Practice Address - Street 2:SUITE #242
Practice Address - City:DALY CITY
Practice Address - State:CA
Practice Address - Zip Code:94015-2621
Practice Address - Country:US
Practice Address - Phone:650-757-3636
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-07
Last Update Date:2015-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA573331223G0001X, 1223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
No1223G0001XDental ProvidersDentistGeneral Practice