MEDICARE: KRISTINE C CHONG D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223P0221X	Pediatric Dentistry	49293	CA

General Provider Information

NPI Number	:	1386707875
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRISTINE C CHONG D.D.S.

Provider Business Mailing Address
First Line	:	255 N SAN MATEO DR STE 3
Second Line	:
City	:	SAN MATEO
State	:	CA
Zip	:	94401-2671
Country	:	US
Telephone Number	:	650-342-1512
Fax Number	:

Provider Business Practice Location Address
First Line	:	33800 ALVARADO NILES RD STE 6
Second Line	:
City	:	UNION CITY
State	:	CA
Zip	:	94587-4359
Country	:	US
Telephone Number	:	510-477-6727
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/18/2006
Last Update Date	:	07/08/2007

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