Provider Demographics
NPI:1295524213
Name:FONG, KELLY (DDS)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:FONG
Suffix:
Gender:
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:244 MONCADA WAY
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94127-2706
Mailing Address - Country:US
Mailing Address - Phone:415-361-2632
Mailing Address - Fax:
Practice Address - Street 1:1636 NORIEGA ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94122-4306
Practice Address - Country:US
Practice Address - Phone:628-628-1636
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-05
Last Update Date:2025-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADDS1105471223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice