MEDICARE: DR. RONALD SAM FENN D.D.S.

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	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	20975	CA

General Provider Information

NPI Number	:	1083615819
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RONALD SAM FENN D.D.S.

Provider Business Mailing Address
First Line	:	1136 N 2ND ST
Second Line	:
City	:	EL CAJON
State	:	CA
Zip	:	92021-5008
Country	:	US
Telephone Number	:	619-444-1181
Fax Number	:	619-444-4552

Provider Business Practice Location Address
First Line	:	1136 N 2ND ST
Second Line	:
City	:	EL CAJON
State	:	CA
Zip	:	92021-5008
Country	:	US
Telephone Number	:	619-444-1181
Fax Number	:	619-444-4552

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

Provider Enumeration Date	:	08/02/2005
Last Update Date	:	07/08/2007

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