Provider Demographics
NPI:1700095403
Name:FAN, STEPHEN T (DMD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
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 1:3618 THORNTON AVE
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94536-7400
Mailing Address - Country:US
Mailing Address - Phone:510-797-2320
Mailing Address - Fax:510-797-2271
Practice Address - Street 1:3618 THORNTON AVE
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94536-7400
Practice Address - Country:US
Practice Address - Phone:510-797-2320
Practice Address - Fax:510-797-2271
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA32955122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist