Provider Demographics
NPI:1215616081
Name:FONG, JOHNSON (DMD)
Entity type:Individual
Prefix:
First Name:JOHNSON
Middle Name:
Last Name:FONG
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 VANE ST
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:MA
Mailing Address - Zip Code:02171-2314
Mailing Address - Country:US
Mailing Address - Phone:781-244-9399
Mailing Address - Fax:
Practice Address - Street 1:193 BOSTON TPKE STE 6140
Practice Address - Street 2:
Practice Address - City:SHREWSBURY
Practice Address - State:MA
Practice Address - Zip Code:01545-2552
Practice Address - Country:US
Practice Address - Phone:508-669-7140
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-17
Last Update Date:2023-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN18598251223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice