MEDICARE: FAISON & FAISON A PROFESSIONAL DENTAL CORPORATION

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	1223P0221X	Pediatric Dentistry	37330	CA
2	1223P0221X	Pediatric Dentistry	25252	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	B2525202	OTHER	CA	DENTI-CAL

General Provider Information

NPI Number	:	1154314060
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FAISON & FAISON A PROFESSIONAL DENTAL CORPORATION

Provider Business Mailing Address
First Line	:	411 S LONG BEACH BLVD
Second Line	:
City	:	COMPTON
State	:	CA
Zip	:	90221-3427
Country	:	US
Telephone Number	:	310-537-2217
Fax Number	:	310-537-8062

Provider Business Practice Location Address
First Line	:	411 S LONG BEACH BLVD
Second Line	:
City	:	COMPTON
State	:	CA
Zip	:	90221-3427
Country	:	US
Telephone Number	:	310-537-2217
Fax Number	:	310-537-8062

Authorized Official
Title or Position	:	CORPORATION SECRETARY
Name	:	DR. ALPHONSO FAISON
Credential	:	DDS
Telephone Number	:	310-537-2217

Provider Enumeration Date	:	08/25/2005
Last Update Date	:	08/22/2020

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Directions to “FAISON & FAISON A PROFESSIONAL DENTAL CORPORATION ” Practice Location

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