Provider Demographics
NPI:1700153475
Name:FANNING, MICHAEL J (DDS, MSD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:J
Last Name:FANNING
Suffix:
Gender:M
Credentials:DDS, MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5507 EAKES RD NW
Mailing Address - Street 2:
Mailing Address - City:LOS RANCHOS
Mailing Address - State:NM
Mailing Address - Zip Code:87107-5529
Mailing Address - Country:US
Mailing Address - Phone:505-400-9855
Mailing Address - Fax:
Practice Address - Street 1:8212 LOUISIANA BLVD NE STE A
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87113-2105
Practice Address - Country:US
Practice Address - Phone:505-400-9855
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-24
Last Update Date:2011-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD33561223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics