Provider Demographics
NPI:1629215660
Name:FAN, KEVIN Y (DDS)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:Y
Last Name:FAN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2176 S ATLANTIC BLVD
Mailing Address - Street 2:
Mailing Address - City:MONTEREY PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91754-6839
Mailing Address - Country:US
Mailing Address - Phone:323-888-0681
Mailing Address - Fax:
Practice Address - Street 1:2176 S ATLANTIC BLVD
Practice Address - Street 2:
Practice Address - City:MONTEREY PARK
Practice Address - State:CA
Practice Address - Zip Code:91754
Practice Address - Country:US
Practice Address - Phone:323-888-0681
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-13
Last Update Date:2019-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA57921122300000X
IL019.0289341223G0001X
CA1034081223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist