Healthcare Provider Details

I. General information

NPI: 1699143917
Provider Name (Legal Business Name): FAN YANG DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/02/2015
Last Update Date: 05/20/2024
Certification Date: 05/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13421 MAPLE AVE FL 3
FLUSHING NY
11355-4527
US

IV. Provider business mailing address

13421 MAPLE AVE FL 3
FLUSHING NY
11355-4527
US

V. Phone/Fax

Practice location:
  • Phone: 603-852-6900
  • Fax:
Mailing address:
  • Phone: 603-852-6900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number059707
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: