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General NPI Number Information
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NPI Number | 1700153475
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Entity Type | Individual
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Provider Name | MICHAEL J FANNING D.D.S., M.S.D.
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Gender | Male
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Dates
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Enumeration Date | 11/24/2011
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Last Update Date | 11/24/2011
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Provider Practice Location Address
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Address Line | 8212 LOUISIANA BLVD NE STE A
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City | ALBUQUERQUE
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State | NM
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Zip | 87113-2105
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Country | US
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Telephone | 505-400-9855
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Fax |
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Provider Business Mailing Address
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Address Line | 5507 EAKES RD NW
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City | LOS RANCHOS
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State | NM
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Zip | 87107-5529
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Country | US
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Telephone | 505-400-9855
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | DD3356
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License Number State | NM
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