=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962578930
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | FENNY VIRGIN D.D.S.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/28/2006
-----------------------------------------------------
Last Update Date | 02/25/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4036 GRAND AVE STE D
-----------------------------------------------------
City | CHINO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91710-5487
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-627-9996
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6877 HIGHLAND DR
-----------------------------------------------------
City | CORONA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92880-3905
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-898-6806
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 53287
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------