Healthcare Provider Details

I. General information

NPI: 1114979002
Provider Name (Legal Business Name): DAN C FONG DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2006
Last Update Date: 06/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4323 HILL ST
COLUMBIA SC
29207-6022
US

IV. Provider business mailing address

4323 HILL ST
COLUMBIA SC
29207-6022
US

V. Phone/Fax

Practice location:
  • Phone: 803-751-5221
  • Fax:
Mailing address:
  • Phone: 803-751-5221
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number41249
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: