Healthcare Provider Details

I. General information

NPI: 1952146060
Provider Name (Legal Business Name): STEPHEN FAN DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/28/2024
Last Update Date: 08/24/2026
Certification Date: 08/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2221 CAMINO DEL RIO S STE 208
SAN DIEGO CA
92108-3611
US

IV. Provider business mailing address

2221 CAMINO DEL RIO S STE 208
SAN DIEGO CA
92108-3611
US

V. Phone/Fax

Practice location:
  • Phone: 619-692-4310
  • Fax:
Mailing address:
  • Phone: 619-692-4310
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number113427
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: