Provider Demographics
NPI:1841490992
Name:DAN W. FONG, D.D.S., A PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:DAN W. FONG, D.D.S., A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DAN
Authorized Official - Middle Name:W
Authorized Official - Last Name:FONG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:916-451-2473
Mailing Address - Street 1:5659 STOCKTON BLVD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95824-1611
Mailing Address - Country:US
Mailing Address - Phone:916-451-2473
Mailing Address - Fax:916-451-0620
Practice Address - Street 1:5659 STOCKTON BLVD
Practice Address - Street 2:SUITE 2
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95824-1611
Practice Address - Country:US
Practice Address - Phone:916-451-2473
Practice Address - Fax:916-451-0620
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-18
Last Update Date:2007-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA28440261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental