=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972521888
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WEN TA FAN DDS PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/18/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4231 COLDEN ST STE 204
-----------------------------------------------------
City | FLUSHING
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11355-3981
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-539-9130
-----------------------------------------------------
Fax | 718-539-9180
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4231 COLDEN ST STE 204
-----------------------------------------------------
City | FLUSHING
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11355-3981
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-539-9130
-----------------------------------------------------
Fax | 718-539-9180
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. WEN TA FAN
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 715-539-9130
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | 047296
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------