Healthcare Provider Details

I. General information

NPI: 1740773423
Provider Name (Legal Business Name): JASON R GONG DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/07/2018
Last Update Date: 09/24/2026
Certification Date: 09/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2325 PALOS VERDES DR W STE 210
PALOS VERDES ESTATES CA
90274-2787
US

IV. Provider business mailing address

2325 PALOS VERDES DR W STE 210
PALOS VERDES ESTATES CA
90274-2787
US

V. Phone/Fax

Practice location:
  • Phone: 310-377-6580
  • Fax: 310-377-3838
Mailing address:
  • Phone: 310-377-6580
  • Fax: 310-377-3838

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number104405
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: