Provider Demographics
NPI:1922602986
Name:MJ FONG DDS DENTAL CORPORATION
Entity Type:Organization
Organization Name:MJ FONG DDS DENTAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:FONG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:916-698-6670
Mailing Address - Street 1:7210 S LAND PARK DR STE E
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95831-3663
Mailing Address - Country:US
Mailing Address - Phone:916-424-0760
Mailing Address - Fax:
Practice Address - Street 1:7210 S LAND PARK DR STE E
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95831-3663
Practice Address - Country:US
Practice Address - Phone:916-424-0760
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-30
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental