Provider Demographics
NPI:1568848174
Name:KU, MARISSA FANG (DDS)
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:FANG
Last Name:KU
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 1:616 N GARFIELD AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:MONTEREY PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91754-1153
Mailing Address - Country:US
Mailing Address - Phone:626-288-0208
Mailing Address - Fax:
Practice Address - Street 1:616 N GARFIELD AVE STE 102
Practice Address - Street 2:
Practice Address - City:MONTEREY PARK
Practice Address - State:CA
Practice Address - Zip Code:91754-1153
Practice Address - Country:US
Practice Address - Phone:626-288-0208
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-05
Last Update Date:2016-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA647471223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice