Provider Demographics
NPI:1609927425
Name:FONG, BRIAN B (DMD, MD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:B
Last Name:FONG
Suffix:
Gender:M
Credentials:DMD, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9390 BIG HORN BLVD.
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95758
Mailing Address - Country:US
Mailing Address - Phone:916-683-7777
Mailing Address - Fax:916-683-8009
Practice Address - Street 1:9390 BIG HORN BLVD.
Practice Address - Street 2:SUITE 100
Practice Address - City:ELK GROVE
Practice Address - State:CA
Practice Address - Zip Code:95758
Practice Address - Country:US
Practice Address - Phone:916-683-7777
Practice Address - Fax:916-683-8009
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA514731223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery