Provider Demographics
NPI:1609344043
Name:FANG, KEVIN (DMD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:FANG
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 E NORMAN AVE
Mailing Address - Street 2:
Mailing Address - City:ARCADIA
Mailing Address - State:CA
Mailing Address - Zip Code:91006-4733
Mailing Address - Country:US
Mailing Address - Phone:626-215-8060
Mailing Address - Fax:
Practice Address - Street 1:8906 SAN BERNARDINO RD STE 130
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-8806
Practice Address - Country:US
Practice Address - Phone:909-944-0152
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-04
Last Update Date:2018-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADDS102717122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist