Healthcare Provider Details

I. General information

NPI: 1992295646
Provider Name (Legal Business Name): FUCONG TIAN BDS, PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2018
Last Update Date: 07/09/2024
Certification Date: 04/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12040 W BROAD STREET
HENRICO VA
23233
US

IV. Provider business mailing address

1612 HUGUENOT ROAD
MIDLOTHIAN VA
23113
US

V. Phone/Fax

Practice location:
  • Phone: 804-364-7010
  • Fax: 706-721-6778
Mailing address:
  • Phone: 804-794-9789
  • Fax: 804-419-1059

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberDE61171559
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number37946
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberDNF000434
License Number StateGA
# 4
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number0401418375
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: