Healthcare Provider Details

I. General information

NPI: 1558194928
Provider Name (Legal Business Name): SHAN GONG DMD MS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2024
Last Update Date: 05/11/2026
Certification Date: 05/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8413 N MILLBROOK AVE STE 101
FRESNO CA
93720-2195
US

IV. Provider business mailing address

8413 N MILLBROOK AVE STE 101
FRESNO CA
93720-2195
US

V. Phone/Fax

Practice location:
  • Phone: 559-448-9000
  • Fax:
Mailing address:
  • Phone: 559-448-9000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X2210X
TaxonomyOrofacial Pain Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. SHAN GONG
Title or Position: PRESIDENT
Credential: DMD, MS
Phone: 559-448-9000