Provider Demographics
NPI:1255818910
Name:NKWETI, FONGALLA (DMD)
Entity type:Individual
Prefix:DR
First Name:FONGALLA
Middle Name:
Last Name:NKWETI
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 1:1443 OGLETHORPE AVE SW
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30310-2528
Mailing Address - Country:US
Mailing Address - Phone:718-915-6598
Mailing Address - Fax:
Practice Address - Street 1:3845 MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:AUSTELL
Practice Address - State:GA
Practice Address - Zip Code:30106-1109
Practice Address - Country:US
Practice Address - Phone:770-944-3737
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-25
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX34420122300000X
GADN1222401223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist