MEDICARE: HENRY FUNG DDS, FAGD, CAMD, LAC

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	122300000X	Dentist	30354	CA
2	171100000X	Acupuncturist	AC1426	CA
3	1223G0001X	General Practice Dentistry	30354	CA

General Provider Information

NPI Number	:	1104075175
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HENRY FUNG DDS, FAGD, CAMD, LAC

Provider Business Mailing Address
First Line	:	5424 E BEVERLY BLVD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90022-2208
Country	:	US
Telephone Number	:	323-721-3312
Fax Number	:	323-721-8822

Provider Business Practice Location Address
First Line	:	5424 E BEVERLY BLVD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90022-2208
Country	:	US
Telephone Number	:	323-721-3312
Fax Number	:	323-721-8822

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

Provider Enumeration Date	:	09/15/2008
Last Update Date	:	01/04/2024

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