Provider Demographics
NPI:1790076735
Name:FONG, JEFFREY (DDS)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:
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 1:9411 65TH RD
Mailing Address - Street 2:SUITE 1B
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374-4627
Mailing Address - Country:US
Mailing Address - Phone:347-682-5688
Mailing Address - Fax:
Practice Address - Street 1:9411 65TH RD
Practice Address - Street 2:SUITE 1B
Practice Address - City:REGO PARK
Practice Address - State:NY
Practice Address - Zip Code:11374-4627
Practice Address - Country:US
Practice Address - Phone:374-682-5688
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-25
Last Update Date:2015-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI025024001223P0221X
NY056689-11223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry