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General NPI Number Information
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NPI Number | 1255456703
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Entity Type | Individual
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Provider Name | HENLEY HERBERT FONG
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Gender | Male
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Dates
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Enumeration Date | 03/20/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 9484 W LAKE MEAD BLVD STE 2
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City | LAS VEGAS
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State | NV
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Zip | 89134-8339
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Country | US
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Telephone | 702-304-8338
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Fax |
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Provider Business Mailing Address
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Address Line | 8000 SPRING MOUNTAIN RD APT 1102
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City | LAS VEGAS
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State | NV
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Zip | 89117-3930
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Country | US
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Telephone | 702-405-9198
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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 | 5279
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License Number State | NV
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