Healthcare Provider Details

I. General information

NPI: 1962938522
Provider Name (Legal Business Name): RAYMOND FAN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2017
Last Update Date: 10/18/2023
Certification Date: 10/18/2023
Deactivation Date: 06/22/2018
Reactivation Date: 07/03/2018

III. Provider practice location address

12860 10TH ST
CHINO CA
91710-4294
US

IV. Provider business mailing address

1600 S ANDREWS AVE
FORT LAUDERDALE FL
33316-2510
US

V. Phone/Fax

Practice location:
  • Phone: 909-591-0241
  • Fax:
Mailing address:
  • Phone: 954-459-2094
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDD5682
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDDS104689
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: