Provider Demographics
NPI:1336260801
Name:FONG, NICKY ANDREW (DDS)
Entity Type:Individual
Prefix:DR
First Name:NICKY
Middle Name:ANDREW
Last Name:FONG
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:NICK
Other - Middle Name:ANDREW
Other - Last Name:FONG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:1735 HUNTERS BLUFF DR
Mailing Address - Street 2:APT. 202
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120-4484
Mailing Address - Country:US
Mailing Address - Phone:901-605-7380
Mailing Address - Fax:
Practice Address - Street 1:831 TIMBER CREEK DR
Practice Address - Street 2:SUITE 1
Practice Address - City:CORDOVA
Practice Address - State:TN
Practice Address - Zip Code:38018-3108
Practice Address - Country:US
Practice Address - Phone:901-754-8080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS0000008438122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist