Provider Demographics
NPI:1932311982
Name:FONG, GLORIA WONG (DDS)
Entity Type:Individual
Prefix:DR
First Name:GLORIA
Middle Name:WONG
Last Name:FONG
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13099 SKYLINE BLVD
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94619-3522
Mailing Address - Country:US
Mailing Address - Phone:510-568-0329
Mailing Address - Fax:
Practice Address - Street 1:363 15TH ST
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94612-3303
Practice Address - Country:US
Practice Address - Phone:510-444-4334
Practice Address - Fax:510-763-8326
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA251391223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice