Provider Demographics
NPI:1821530635
Name:DUCHESS DENTAL PLLC
Entity Type:Organization
Organization Name:DUCHESS DENTAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:
Authorized Official - Last Name:FAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:347-688-9827
Mailing Address - Street 1:4301 W WILLIAM CANNON DR
Mailing Address - Street 2:SUITE B240
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78749-1473
Mailing Address - Country:US
Mailing Address - Phone:512-892-7800
Mailing Address - Fax:512-892-7802
Practice Address - Street 1:4301 W WILLIAM CANNON DR
Practice Address - Street 2:SUITE B240
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78749-1473
Practice Address - Country:US
Practice Address - Phone:512-892-7800
Practice Address - Fax:512-892-7802
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-09
Last Update Date:2016-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty