Provider Demographics
NPI:1336637909
Name:FONG, JOEL A
Entity Type:Individual
Prefix:
First Name:JOEL
Middle Name:A
Last Name:FONG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3180 COUNTRY CLUB DR APT 3B
Mailing Address - Street 2:
Mailing Address - City:CAMERON PARK
Mailing Address - State:CA
Mailing Address - Zip Code:95682-8546
Mailing Address - Country:US
Mailing Address - Phone:510-393-3727
Mailing Address - Fax:
Practice Address - Street 1:1350 E MAIN ST
Practice Address - Street 2:
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945-5208
Practice Address - Country:US
Practice Address - Phone:530-477-8545
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-28
Last Update Date:2021-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADDS1043411223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty