Provider Demographics
NPI:1205931755
Name:FAN, TERRENCE T (DMD)
Entity type:Individual
Prefix:DR
First Name:TERRENCE
Middle Name:T
Last Name:FAN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:821 S 9TH ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19147-2822
Mailing Address - Country:US
Mailing Address - Phone:215-629-0599
Mailing Address - Fax:215-629-0596
Practice Address - Street 1:821 S 9TH ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19147-2822
Practice Address - Country:US
Practice Address - Phone:215-629-0599
Practice Address - Fax:215-629-0596
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS-030933-L1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice