Healthcare Provider Details

I. General information

NPI: 1174620769
Provider Name (Legal Business Name): HENRY K PONG, DDS, PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/17/2006
Last Update Date: 02/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3820 CENTRAL AVE
LAKE STATION IN
46405-2324
US

IV. Provider business mailing address

3820 CENTRAL AVE
LAKE STATION IN
46405-2324
US

V. Phone/Fax

Practice location:
  • Phone: 219-962-8666
  • Fax:
Mailing address:
  • Phone: 219-962-8666
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number54000645
License Number StateIN

VIII. Authorized Official

Name: DR. HENRY K PONG
Title or Position: PRESIDENT
Credential: DDS
Phone: 219-962-8666