MEDICARE: DR. JENNIFER FANG

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	D6579	AZ

General Provider Information

NPI Number	:	1235127325
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JENNIFER FANG

Provider Business Mailing Address
First Line	:	17360 COLIMA RD
Second Line	:	#159
City	:	ROWLAND HEIGHTS
State	:	CA
Zip	:	91748-1628
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2080 W SOUTHERN AVE
Second Line	:	STE. A-3
City	:	APACHE JUNCTION
State	:	AZ
Zip	:	85220-7455
Country	:	US
Telephone Number	:	480-288-2003
Fax Number	:

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

Provider Enumeration Date	:	10/12/2005
Last Update Date	:	07/08/2007

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Directions to “ DR. JENNIFER FANG ” Practice Location

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