Provider Demographics
NPI:1871628446
Name:TOMMY FONG, DDS, VIVIAN M. BENNETT, DDS, PC
Entity type:Organization
Organization Name:TOMMY FONG, DDS, VIVIAN M. BENNETT, DDS, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:DR
Authorized Official - First Name:VIVIAN
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:206-542-7000
Mailing Address - Street 1:735 N 185TH ST
Mailing Address - Street 2:
Mailing Address - City:SHORELINE
Mailing Address - State:WA
Mailing Address - Zip Code:98133-3901
Mailing Address - Country:US
Mailing Address - Phone:206-542-7000
Mailing Address - Fax:
Practice Address - Street 1:735 N 185TH ST
Practice Address - Street 2:
Practice Address - City:SHORELINE
Practice Address - State:WA
Practice Address - Zip Code:98133-3901
Practice Address - Country:US
Practice Address - Phone:206-542-7000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000060351223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty