Healthcare Provider Details

I. General information

NPI: 1629535182
Provider Name (Legal Business Name): WENDY CROCUS FANG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/20/2019
Last Update Date: 07/10/2026
Certification Date: 07/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

883 SNEATH LN STE 130
SAN BRUNO CA
94066-2409
US

IV. Provider business mailing address

690 LOS PALMOS DR
SAN FRANCISCO CA
94127-2212
US

V. Phone/Fax

Practice location:
  • Phone: 650-589-4563
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number107805
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: