MEDICARE: DR. TERRENCE T. FAN D.M.D

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	1223G0001X	General Practice Dentistry	DS-030933-L	PA

General Provider Information

NPI Number	:	1205931755
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TERRENCE T. FAN D.M.D

Provider Business Mailing Address
First Line	:	821 S 9TH ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19147-2822
Country	:	US
Telephone Number	:	215-629-0599
Fax Number	:	215-629-0596

Provider Business Practice Location Address
First Line	:	821 S 9TH ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19147-2822
Country	:	US
Telephone Number	:	215-629-0599
Fax Number	:	215-629-0596

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

Provider Enumeration Date	:	09/13/2006
Last Update Date	:	07/08/2007

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