Provider Demographics
NPI:1508982109
Name:KONG, DANA LYLE (DDS)
Entity Type:Individual
Prefix:MR
First Name:DANA
Middle Name:LYLE
Last Name:KONG
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 1:109 E WILLIAMS ST
Mailing Address - Street 2:
Mailing Address - City:OWOSSO
Mailing Address - State:MI
Mailing Address - Zip Code:48867
Mailing Address - Country:US
Mailing Address - Phone:989-723-6118
Mailing Address - Fax:989-724-9588
Practice Address - Street 1:109 E WILLIAMS ST
Practice Address - Street 2:
Practice Address - City:OWOSSO
Practice Address - State:MI
Practice Address - Zip Code:48867-2360
Practice Address - Country:US
Practice Address - Phone:989-723-6118
Practice Address - Fax:989-729-9588
Is Sole Proprietor?:No
Enumeration Date:2007-03-22
Last Update Date:2022-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010159941223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice