Provider Demographics
NPI:1710957329
Name:XU, SHAOFAN KEVIN (DDS MS)
Entity Type:Individual
Prefix:
First Name:SHAOFAN
Middle Name:KEVIN
Last Name:XU
Suffix:
Gender:M
Credentials:DDS MS
Other - Prefix:
Other - First Name:KEVIN
Other - Middle Name:
Other - Last Name:XU
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS MS PS
Mailing Address - Street 1:5038 TACOMA MALL BLVD
Mailing Address - Street 2:STE. A
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98409
Mailing Address - Country:US
Mailing Address - Phone:253-473-2166
Mailing Address - Fax:253-473-2167
Practice Address - Street 1:5038 TACOMA MALL BLVD
Practice Address - Street 2:STE. A
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98409
Practice Address - Country:US
Practice Address - Phone:253-473-2166
Practice Address - Fax:253-473-2167
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2011-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA6938122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist