Healthcare Provider Details

I. General information

NPI: 1235701053
Provider Name (Legal Business Name): JENNY FANG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2021
Last Update Date: 12/07/2022
Certification Date: 07/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

803 39TH AVE SW STE F
PUYALLUP WA
98373-3692
US

IV. Provider business mailing address

26205 116TH AVE SE APT A302
KENT WA
98030-8445
US

V. Phone/Fax

Practice location:
  • Phone: 253-445-1500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDE61178265
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDE61178265
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: