=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063905453
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ZHIYONG FAN DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/11/2018
-----------------------------------------------------
Last Update Date | 07/01/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1640 HIGHLAND FALLS DR STE 901
-----------------------------------------------------
City | LEANDER
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78641-4841
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-986-7196
-----------------------------------------------------
Fax | 512-986-7835
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 16238 RR 620 N STE F194
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78717-5212
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-380-8476
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 34007
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------