Provider Demographics
NPI:1215904008
Name:FONG, TERESA L (DDS)
Entity type:Individual
Prefix:DR
First Name:TERESA
Middle Name:L
Last Name:FONG
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:TERESA
Other - Middle Name:F
Other - Last Name:SIT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1021 BANDANA BLVD E
Mailing Address - Street 2:SUITE 121
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55108-5113
Mailing Address - Country:US
Mailing Address - Phone:651-224-4969
Mailing Address - Fax:651-223-8047
Practice Address - Street 1:1021 BANDANA BLVD E
Practice Address - Street 2:SUITE 121
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55108-5113
Practice Address - Country:US
Practice Address - Phone:651-224-4969
Practice Address - Fax:651-223-8047
Is Sole Proprietor?:No
Enumeration Date:2006-03-01
Last Update Date:2016-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNA102791223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN293322500Medicaid