Healthcare Provider Details

I. General information

NPI: 1235127325
Provider Name (Legal Business Name): DR. JENNIFER FANG
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/12/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2080 W SOUTHERN AVE STE. A-3
APACHE JUNCTION AZ
85220-7455
US

IV. Provider business mailing address

17360 COLIMA RD #159
ROWLAND HEIGHTS CA
91748-1628
US

V. Phone/Fax

Practice location:
  • Phone: 480-288-2003
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD6579
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: