Provider Demographics
NPI:1164751426
Name:FANG, MICHELLE M (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:M
Last Name:FANG
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5066
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92616-5066
Mailing Address - Country:US
Mailing Address - Phone:714-292-6466
Mailing Address - Fax:
Practice Address - Street 1:301 1/2 N MAIN ST
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92701-4852
Practice Address - Country:US
Practice Address - Phone:714-292-6466
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-16
Last Update Date:2009-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA43336122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist