Provider Demographics
NPI:1497806582
Name:MOU, FAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:FAN
Middle Name:
Last Name:MOU
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 1:560 RIVERSIDE DR
Mailing Address - Street 2:APT #5G
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10027-3202
Mailing Address - Country:US
Mailing Address - Phone:917-526-2946
Mailing Address - Fax:
Practice Address - Street 1:128 MOTT ST
Practice Address - Street 2:SUITE 203
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10013-5540
Practice Address - Country:US
Practice Address - Phone:212-965-8113
Practice Address - Fax:212-965-8114
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0522121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02743382Medicaid