Provider Demographics
NPI:1447910989
Name:FANG, DEXTER
Entity type:Individual
Prefix:
First Name:DEXTER
Middle Name:
Last Name:FANG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 E PLAZA BLVD
Mailing Address - Street 2:
Mailing Address - City:NATIONAL CITY
Mailing Address - State:CA
Mailing Address - Zip Code:91950-3609
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1201 E PLAZA BLVD
Practice Address - Street 2:
Practice Address - City:NATIONAL CITY
Practice Address - State:CA
Practice Address - Zip Code:91950-3609
Practice Address - Country:US
Practice Address - Phone:619-477-7114
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-24
Last Update Date:2021-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA84990183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist