MEDICARE: DR. NICKY ANDREW FONG D.D.S.

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	122300000X	Dentist	DS0000008438	TN

General Provider Information

NPI Number	:	1336260801
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. NICKY ANDREW FONG D.D.S.

Provider Business Mailing Address
First Line	:	1735 HUNTERS BLUFF DR
Second Line	:	APT. 202
City	:	MEMPHIS
State	:	TN
Zip	:	38120-4484
Country	:	US
Telephone Number	:	901-605-7380
Fax Number	:

Provider Business Practice Location Address
First Line	:	831 TIMBER CREEK DR
Second Line	:	SUITE 1
City	:	CORDOVA
State	:	TN
Zip	:	38018-3108
Country	:	US
Telephone Number	:	901-754-8080
Fax Number	:

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

Provider Enumeration Date	:	04/03/2007
Last Update Date	:	07/08/2007

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