Provider Demographics
NPI:1275123481
Name:RONG, FRED ANDE (DDS)
Entity Type:Individual
Prefix:
First Name:FRED
Middle Name:ANDE
Last Name:RONG
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 1:16997 FRANK AVE
Mailing Address - Street 2:
Mailing Address - City:LOS GATOS
Mailing Address - State:CA
Mailing Address - Zip Code:95032-3453
Mailing Address - Country:US
Mailing Address - Phone:408-439-4601
Mailing Address - Fax:
Practice Address - Street 1:1959 NE PACIFIC STREET HSB ROOM B 241
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98195-1300
Practice Address - Country:US
Practice Address - Phone:206-543-7496
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-21
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE7671122300000X
WADR61427419204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No122300000XDental ProvidersDentist