Provider Demographics
NPI:1912367269
Name:GONG, SHAN (DMD)
Entity Type:Individual
Prefix:
First Name:SHAN
Middle Name:
Last Name:GONG
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 10059
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93389-0059
Mailing Address - Country:US
Mailing Address - Phone:661-328-0876
Mailing Address - Fax:661-327-4733
Practice Address - Street 1:111 E 210TH ST
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10467-2401
Practice Address - Country:US
Practice Address - Phone:781-920-4321
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-29
Last Update Date:2019-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1016931223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty