Provider Demographics
NPI:1396026191
Name:FONG, KIMBERLY ANN (RDHAP)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ANN
Last Name:FONG
Suffix:
Gender:F
Credentials:RDHAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 171
Mailing Address - Street 2:
Mailing Address - City:BRISBANE
Mailing Address - State:CA
Mailing Address - Zip Code:94005-0171
Mailing Address - Country:US
Mailing Address - Phone:415-640-3274
Mailing Address - Fax:650-593-3327
Practice Address - Street 1:876 BOARDWALK PLACE
Practice Address - Street 2:
Practice Address - City:REDWOOD CITY
Practice Address - State:CA
Practice Address - Zip Code:94065-1809
Practice Address - Country:US
Practice Address - Phone:415-640-3274
Practice Address - Fax:650-593-3327
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-07
Last Update Date:2011-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAHAP353124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist