Healthcare Provider Details

I. General information

NPI: 1154314060
Provider Name (Legal Business Name): FAISON & FAISON A PROFESSIONAL DENTAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/25/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

411 S LONG BEACH BLVD
COMPTON CA
90221-3427
US

IV. Provider business mailing address

411 S LONG BEACH BLVD
COMPTON CA
90221-3427
US

V. Phone/Fax

Practice location:
  • Phone: 310-537-2217
  • Fax: 310-537-8062
Mailing address:
  • Phone: 310-537-2217
  • Fax: 310-537-8062

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number37330
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number25252
License Number StateCA

VIII. Authorized Official

Name: DR. ALPHONSO FAISON
Title or Position: CORPORATION SECRETARY
Credential: DDS
Phone: 310-537-2217