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General NPI Number Information
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NPI Number | 1174127138
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Entity Type | Individual
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Provider Name | GRANT RUSSELL FONG DDS
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Gender | Male
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Dates
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Enumeration Date | 11/30/2020
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Last Update Date | 11/30/2020
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Provider Practice Location Address
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Address Line | 3000 L ST STE 215
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City | SACRAMENTO
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State | CA
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Zip | 95816-5248
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Country | US
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Telephone | 916-457-7080
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Fax |
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Provider Business Mailing Address
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Address Line | 820 COBBLE COVE LN
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City | SACRAMENTO
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State | CA
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Zip | 95831-4309
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Country | US
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Telephone | 916-217-3177
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | DDS105756
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License Number State | CA
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