=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619376027
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RYAN JAMES FAIT D.D.S.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/21/2014
-----------------------------------------------------
Last Update Date | 10/26/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2700 N BELLFLOWER BLVD SUITE#206
-----------------------------------------------------
City | LONG BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90815-2421
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 562-982-1552
-----------------------------------------------------
Fax | 562-425-3412
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2700 N BELLFLOWER BLVD STE 206
-----------------------------------------------------
City | LONG BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90815-1144
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 562-982-1552
-----------------------------------------------------
Fax | 562-425-3412
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 63614
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------