Provider Demographics
NPI:1285776336
Name:BETTY J. FONG DDS, A PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:BETTY J. FONG DDS, A PROFESSIONAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BETTY
Authorized Official - Middle Name:
Authorized Official - Last Name:FONG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:510-741-2140
Mailing Address - Street 1:500 ALFRED NOBEL DR
Mailing Address - Street 2:SUITE 240
Mailing Address - City:HERCULES
Mailing Address - State:CA
Mailing Address - Zip Code:94547-1838
Mailing Address - Country:US
Mailing Address - Phone:510-741-2140
Mailing Address - Fax:
Practice Address - Street 1:500 ALFRED NOBEL DR
Practice Address - Street 2:SUITE 240
Practice Address - City:HERCULES
Practice Address - State:CA
Practice Address - Zip Code:94547-1838
Practice Address - Country:US
Practice Address - Phone:510-741-2140
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-13
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty