Healthcare Provider Details

I. General information

NPI: 1700153475
Provider Name (Legal Business Name): MICHAEL J FANNING D.D.S., M.S.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/24/2011
Last Update Date: 11/24/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8212 LOUISIANA BLVD NE STE A
ALBUQUERQUE NM
87113-2105
US

IV. Provider business mailing address

5507 EAKES RD NW
LOS RANCHOS NM
87107-5529
US

V. Phone/Fax

Practice location:
  • Phone: 505-400-9855
  • Fax:
Mailing address:
  • Phone: 505-400-9855
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDD3356
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: