Provider Demographics
NPI:1821112400
Name:FONG, CHUNG H (DDS)
Entity Type:Individual
Prefix:DR
First Name:CHUNG
Middle Name:H
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 1:2525 K ST.
Mailing Address - Street 2:#306
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95816
Mailing Address - Country:US
Mailing Address - Phone:916-442-8553
Mailing Address - Fax:
Practice Address - Street 1:2525 K ST.
Practice Address - Street 2:#306
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95816
Practice Address - Country:US
Practice Address - Phone:916-442-8553
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA172761223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice