MEDICARE: KELLY FONG DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	DDS110547	CA

General Provider Information

NPI Number	:	1295524213
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY FONG DDS

Provider Business Mailing Address
First Line	:	244 MONCADA WAY
Second Line	:
City	:	SAN FRANCISCO
State	:	CA
Zip	:	94127-2706
Country	:	US
Telephone Number	:	415-361-2632
Fax Number	:

Provider Business Practice Location Address
First Line	:	1636 NORIEGA ST
Second Line	:
City	:	SAN FRANCISCO
State	:	CA
Zip	:	94122-4306
Country	:	US
Telephone Number	:	628-628-1636
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/05/2025
Last Update Date	:	05/05/2025

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