MEDICARE: GREGORY LAWRENCE KONG 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	1223G0001X	General Practice Dentistry	25925	CA

General Provider Information

NPI Number	:	1629169123
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GREGORY LAWRENCE KONG D.D.S.

Provider Business Mailing Address
First Line	:	545 BARBARA WAY
Second Line	:
City	:	HILLSBOROUGH
State	:	CA
Zip	:	94010-6703
Country	:	US
Telephone Number	:	650-343-6678
Fax Number	:

Provider Business Practice Location Address
First Line	:	151 CALLAN AVE
Second Line	:	SUITE 302
City	:	SAN LEANDRO
State	:	CA
Zip	:	94577-4536
Country	:	US
Telephone Number	:	510-351-7130
Fax Number	:

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

Provider Enumeration Date	:	09/28/2006
Last Update Date	:	07/08/2007

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