Provider Demographics
NPI:1558576447
Name:GONG, RONG (DDS)
Entity Type:Individual
Prefix:DR
First Name:RONG
Middle Name:
Last Name:GONG
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10595 MATINAL CIR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92127-1267
Mailing Address - Country:US
Mailing Address - Phone:858-228-7957
Mailing Address - Fax:858-451-0628
Practice Address - Street 1:742 BROADWAY
Practice Address - Street 2:
Practice Address - City:EL CAJON
Practice Address - State:CA
Practice Address - Zip Code:92021-4630
Practice Address - Country:US
Practice Address - Phone:858-228-7957
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA53703122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist