Provider Demographics
NPI:1124436043
Name:DUPANOVIC, JUSTINE FONG (DDS)
Entity type:Individual
Prefix:DR
First Name:JUSTINE
Middle Name:FONG
Last Name:DUPANOVIC
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7672 HOWERTON DR
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95831-4105
Mailing Address - Country:US
Mailing Address - Phone:916-599-6290
Mailing Address - Fax:
Practice Address - Street 1:1201 N NEVADA ST
Practice Address - Street 2:
Practice Address - City:CARSON CITY
Practice Address - State:NV
Practice Address - Zip Code:89703-3810
Practice Address - Country:US
Practice Address - Phone:775-882-2290
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-23
Last Update Date:2019-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA63697122300000X
NV7243122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist