Provider Demographics
NPI:1124157011
Name:FONG, BRUCE DAVID (DDS)
Entity type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:DAVID
Last Name:FONG
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:BRUCE
Other - Middle Name:DAVID
Other - Last Name:FONG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:20 HILTON CT
Mailing Address - Street 2:
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94595-1315
Mailing Address - Country:US
Mailing Address - Phone:925-988-0433
Mailing Address - Fax:
Practice Address - Street 1:5655 COLLEGE AVE
Practice Address - Street 2:SUITE 312
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94618-1583
Practice Address - Country:US
Practice Address - Phone:510-653-6677
Practice Address - Fax:510-653-6689
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA396361223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice