Provider Demographics
NPI:1629169123
Name:KONG, GREGORY LAWRENCE (DDS)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:LAWRENCE
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 1:545 BARBARA WAY
Mailing Address - Street 2:
Mailing Address - City:HILLSBOROUGH
Mailing Address - State:CA
Mailing Address - Zip Code:94010-6703
Mailing Address - Country:US
Mailing Address - Phone:650-343-6678
Mailing Address - Fax:
Practice Address - Street 1:151 CALLAN AVE
Practice Address - Street 2:SUITE 302
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94577-4536
Practice Address - Country:US
Practice Address - Phone:510-351-7130
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA259251223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice