Provider Demographics
NPI:1952475238
Name:FAN, LAURIE (DDS)
Entity Type:Individual
Prefix:DR
First Name:LAURIE
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 1:8012 17TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98115-4420
Mailing Address - Country:US
Mailing Address - Phone:206-523-6506
Mailing Address - Fax:
Practice Address - Street 1:10700 SE 174TH ST STE 101
Practice Address - Street 2:
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98055-5472
Practice Address - Country:US
Practice Address - Phone:206-296-4955
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE00005993122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5019591Medicaid