MEDICARE: DR. VICTOR S. C. FAN DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223E0200X	Endodontics	34092	CA

General Provider Information

NPI Number	:	1053454231
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. VICTOR S. C. FAN DMD

Provider Business Mailing Address
First Line	:	3958 ATLANTIC AVE
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90807-3502
Country	:	US
Telephone Number	:	562-424-1153
Fax Number	:	562-424-4445

Provider Business Practice Location Address
First Line	:	3958 ATLANTIC AVE
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90807-3502
Country	:	US
Telephone Number	:	562-424-1153
Fax Number	:	562-424-4445

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/15/2007
Last Update Date	:	07/08/2007

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