Healthcare Provider Details

I. General information

NPI: 1235385493
Provider Name (Legal Business Name): JENNIFER MELISSA FONG DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/07/2008
Last Update Date: 01/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 GELLERT BLVD SUITE #242
DALY CITY CA
94015-2621
US

IV. Provider business mailing address

333 GELLERT BLVD SUITE #242
DALY CITY CA
94015-2621
US

V. Phone/Fax

Practice location:
  • Phone: 650-757-3636
  • Fax:
Mailing address:
  • Phone: 650-757-3636
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number57333
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number57333
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: