Provider Demographics
NPI:1497706253
Name:FONG-SOTO, RICHARD ALEJANDRO (DDS)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:ALEJANDRO
Last Name:FONG-SOTO
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 1:3901 CAPITAL BLVD
Mailing Address - Street 2:161
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27604-3488
Mailing Address - Country:US
Mailing Address - Phone:919-301-8622
Mailing Address - Fax:
Practice Address - Street 1:3901 CAPITAL BLVD
Practice Address - Street 2:161
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27604-3488
Practice Address - Country:US
Practice Address - Phone:919-301-8622
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-15
Last Update Date:2008-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0497371122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02655223Medicaid