Individual
DR. FAN MOU
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
D.D.S
Contact information
Practice address
128 MOTT ST, SUITE 203, NEW YORK, NY 10013-5540
(212) 965-8113
(212) 965-8114
Mailing address
560 RIVERSIDE DR, APT #5G, NEW YORK, NY 10027-3202
(917) 526-2946
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
Primary
052212
NY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
02743382
—
NY
Enumeration date
01/15/2007
Last updated
07/08/2007
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