Provider Demographics
NPI:1366652117
Name:FONG, LAWRENCE EUGENE (DDS)
Entity Type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:EUGENE
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 1:61A BROADWAY BLVD
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:CA
Mailing Address - Zip Code:94930-1653
Mailing Address - Country:US
Mailing Address - Phone:415-457-3377
Mailing Address - Fax:415-459-6218
Practice Address - Street 1:61A BROADWAY BLVD
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:CA
Practice Address - Zip Code:94930-1653
Practice Address - Country:US
Practice Address - Phone:415-457-3377
Practice Address - Fax:415-459-6218
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA220681223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice