Healthcare Provider Details

I. General information

NPI: 1376200204
Provider Name (Legal Business Name): JENNIFER FONG DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/27/2021
Last Update Date: 11/27/2021
Certification Date: 11/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

66 SOMME ST
NEWARK NJ
07105-3612
US

IV. Provider business mailing address

384 PATERSON AVE # 206
EAST RUTHERFORD NJ
07073-1339
US

V. Phone/Fax

Practice location:
  • Phone: 973-288-2723
  • Fax:
Mailing address:
  • Phone: 916-607-4992
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number22DI02869600
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: