Provider Demographics
NPI:1164645750
Name:FAN, WEN S (DMD, MD)
Entity Type:Individual
Prefix:DR
First Name:WEN
Middle Name:S
Last Name:FAN
Suffix:
Gender:M
Credentials:DMD, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1235 BROCKTON AVE
Mailing Address - Street 2:#206
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-1344
Mailing Address - Country:US
Mailing Address - Phone:310-770-5498
Mailing Address - Fax:
Practice Address - Street 1:2039 FOREST AVE STE 306
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95128-4830
Practice Address - Country:US
Practice Address - Phone:408-298-7775
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-11
Last Update Date:2009-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA52603122300000X, 1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No122300000XDental ProvidersDentist