Provider Demographics
NPI:1447631486
Name:GONG, AMINA YIXUAN (DDS)
Entity type:Individual
Prefix:DR
First Name:AMINA
Middle Name:YIXUAN
Last Name:GONG
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:YIXUAN
Other - Middle Name:
Other - Last Name:GONG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:579 NEWFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06905-3302
Mailing Address - Country:US
Mailing Address - Phone:203-890-9300
Mailing Address - Fax:
Practice Address - Street 1:579 NEWFIELD AVE
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06905-3302
Practice Address - Country:US
Practice Address - Phone:203-890-9300
Practice Address - Fax:203-890-9250
Is Sole Proprietor?:No
Enumeration Date:2015-06-16
Last Update Date:2020-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY058587122300000X
390200000X
CT12540122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04803581Medicaid