MEDICARE: DR. ANDREW B. FONG 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	1223G0001X	General Practice Dentistry	38420	CA

General Provider Information

NPI Number	:	1487754214
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ANDREW B. FONG D.D.S.

Provider Business Mailing Address
First Line	:	4000 S BASCOM AVE
Second Line	:	SUITE 8
City	:	SAN JOSE
State	:	CA
Zip	:	95124-2663
Country	:	US
Telephone Number	:	408-377-5833
Fax Number	:	408-377-3383

Provider Business Practice Location Address
First Line	:	4000 S BASCOM AVE
Second Line	:	SUITE 8
City	:	SAN JOSE
State	:	CA
Zip	:	95124-2663
Country	:	US
Telephone Number	:	408-377-5833
Fax Number	:	408-377-3383

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

Provider Enumeration Date	:	09/22/2006
Last Update Date	:	11/15/2011

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