Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | 41248 | CA |
NPI | 1003912528 |
---|---|
Provider Name | Dr. Kevin David Fong |
First Address | Hayward, CA 94545-1521 |
Second Address | Hayward, CA 94545-1521 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 15/09/2006 |
Last Update Date | 17/07/2008 |