Healthcare Provider Details

I. General information

NPI: 1912367269
Provider Name (Legal Business Name): SHAN GONG D.M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/29/2016
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: 559-449-1142

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X2210X
TaxonomyOrofacial Pain Dentistry
License Number101693
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: