Provider Demographics
NPI:1396531281
Name:FAN, XIAOJING
Entity type:Individual
Prefix:
First Name:XIAOJING
Middle Name:
Last Name:FAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1021 WICKER WAY
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32117-4590
Mailing Address - Country:US
Mailing Address - Phone:813-734-5894
Mailing Address - Fax:
Practice Address - Street 1:1765 DUNLAWTON AVE STE 103
Practice Address - Street 2:
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32127-4717
Practice Address - Country:US
Practice Address - Phone:386-259-3905
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-16
Last Update Date:2025-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLDN30796122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program