Provider Demographics
NPI:1336595057
Name:FAN, YIJIAO (DDS)
Entity Type:Individual
Prefix:DR
First Name:YIJIAO
Middle Name:
Last Name:FAN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14238 37TH AVE STE 1G
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11354-4580
Mailing Address - Country:US
Mailing Address - Phone:347-943-1960
Mailing Address - Fax:
Practice Address - Street 1:14238 37TH AVE STE 1G
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11354-4580
Practice Address - Country:US
Practice Address - Phone:347-943-1960
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-11
Last Update Date:2022-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0625961223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery