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General NPI Number Information
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NPI Number | 1619307105
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Entity Type | Organization
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Legal Business Name | FAN OF DENTISTRY PLLC
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Dates
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Enumeration Date | 11/19/2013
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Last Update Date | 11/19/2013
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Provider Practice Location Address
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Address Line | 689 W RENNER RD
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City | RICHARDSON
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State | TX
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Zip | 75080-1345
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Country | US
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Telephone | 972-234-5700
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Fax |
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Provider Business Mailing Address
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Address Line | 4517 TUSCANY DR
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City | PLANO
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State | TX
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Zip | 75093-7043
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Country | US
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Telephone | 214-395-1217
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | BENJAMIN FAN
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Credential | D.D.S.
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Telephone | 214-395-1217
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 25777
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License Number State | TX
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