Provider Demographics
NPI:1568449197
Name:FONG, IAN SHANE (DDS)
Entity Type:Individual
Prefix:DR
First Name:IAN
Middle Name:SHANE
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 1:1900 N UNIVERSITY DR
Mailing Address - Street 2:STE 201
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33024-3618
Mailing Address - Country:US
Mailing Address - Phone:954-432-8992
Mailing Address - Fax:954-432-8843
Practice Address - Street 1:1900 N UNIVERSITY DR
Practice Address - Street 2:STE 201
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33024-3618
Practice Address - Country:US
Practice Address - Phone:954-432-8992
Practice Address - Fax:954-432-8843
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN151501223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice