Healthcare Provider Details

I. General information

NPI: 1275123481
Provider Name (Legal Business Name): FRED ANDE RONG DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/21/2021
Last Update Date: 04/02/2025
Certification Date: 04/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

155 N FRESNO ST
FRESNO CA
93701-2302
US

IV. Provider business mailing address

155 N FRESNO ST
FRESNO CA
93701-2302
US

V. Phone/Fax

Practice location:
  • Phone: 559-459-4182
  • Fax:
Mailing address:
  • Phone: 559-459-4182
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number106803
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: