Provider Demographics
NPI:1811070295
Name:FAN, SIUMAN (DDS)
Entity type:Individual
Prefix:DR
First Name:SIUMAN
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 1:12262 GINSTAR CT
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92131-3841
Mailing Address - Country:US
Mailing Address - Phone:858-536-9848
Mailing Address - Fax:
Practice Address - Street 1:2020 CAMINO DEL RIO N
Practice Address - Street 2:101
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-1541
Practice Address - Country:US
Practice Address - Phone:619-692-4310
Practice Address - Fax:619-692-4327
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA362411223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice