Provider Demographics
NPI:1255456703
Name:FONG, HENLEY HERBERT
Entity type:Individual
Prefix:
First Name:HENLEY
Middle Name:HERBERT
Last Name:FONG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8000 SPRING MOUNTAIN RD APT 1102
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89117-3930
Mailing Address - Country:US
Mailing Address - Phone:702-405-9198
Mailing Address - Fax:
Practice Address - Street 1:9484 W LAKE MEAD BLVD STE 2
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89134-8339
Practice Address - Country:US
Practice Address - Phone:702-304-8338
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV52791223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice