Provider Demographics
NPI:1710614532
Name:FAN, XIN (DDS)
Entity Type:Individual
Prefix:
First Name:XIN
Middle Name:
Last Name:FAN
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 1:555 PACIFIC AVE APT 225
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95060-7177
Mailing Address - Country:US
Mailing Address - Phone:858-900-8326
Mailing Address - Fax:
Practice Address - Street 1:1895 MAIN ST
Practice Address - Street 2:
Practice Address - City:WATSONVILLE
Practice Address - State:CA
Practice Address - Zip Code:95076-6024
Practice Address - Country:US
Practice Address - Phone:831-271-3214
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-02
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADDS1076641223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice