Provider Demographics
NPI:1912367269
Name:GONG, SHAN (DMD)
Entity type:Individual
Prefix:
First Name:SHAN
Middle Name:
Last Name:GONG
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8413 N MILLBROOK AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720-2195
Mailing Address - Country:US
Mailing Address - Phone:559-448-9000
Mailing Address - Fax:559-449-1142
Practice Address - Street 1:8413 N MILLBROOK AVE STE 101
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-2195
Practice Address - Country:US
Practice Address - Phone:559-448-9000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-29
Last Update Date:2024-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1016931223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty