Provider Demographics
NPI:1558194928
Name:SHAN GONG DMD MS INC
Entity type:Organization
Organization Name:SHAN GONG DMD MS INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:GONG
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MS
Authorized Official - Phone:559-448-9000
Mailing Address - Street 1:8413 N MILLBROOK AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720-2195
Mailing Address - Country:US
Mailing Address - Phone:559-448-9000
Mailing Address - Fax:
Practice Address - Street 1:8413 N MILLBROOK AVE STE 101
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-2195
Practice Address - Country:US
Practice Address - Phone:559-448-9000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-21
Last Update Date:2025-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty