Healthcare Provider Details

I. General information

NPI: 1255818910
Provider Name (Legal Business Name): FONGALLA NKWETI DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2018
Last Update Date: 09/06/2023
Certification Date: 09/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3845 MEDICAL PARK DR
AUSTELL GA
30106-1109
US

IV. Provider business mailing address

1443 OGLETHORPE AVE SW
ATLANTA GA
30310-2528
US

V. Phone/Fax

Practice location:
  • Phone: 770-944-3737
  • Fax:
Mailing address:
  • Phone: 718-915-6598
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number34420
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN122240
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: