MEDICARE: SHAN GONG DMD MS INC

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	1223X2210X	Orofacial Pain Dentistry

General Provider Information

NPI Number	:	1558194928
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SHAN GONG DMD MS INC

Provider Business Mailing Address
First Line	:	8413 N MILLBROOK AVE STE 101
Second Line	:
City	:	FRESNO
State	:	CA
Zip	:	93720-2195
Country	:	US
Telephone Number	:	559-448-9000
Fax Number	:

Provider Business Practice Location Address
First Line	:	8413 N MILLBROOK AVE STE 101
Second Line	:
City	:	FRESNO
State	:	CA
Zip	:	93720-2195
Country	:	US
Telephone Number	:	559-448-9000
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. SHAN GONG
Credential	:	DMD, MS
Telephone Number	:	559-448-9000

Provider Enumeration Date	:	08/21/2024
Last Update Date	:	05/11/2026

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