Provider Demographics
NPI:1447967641
Name:XU, FAN
Entity type:Individual
Prefix:DR
First Name:FAN
Middle Name:
Last Name:XU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:626 2ND AVENUE SOUTH
Mailing Address - Street 2:P.O. BOX 1340
Mailing Address - City:OKANOGAN
Mailing Address - State:WA
Mailing Address - Zip Code:98840
Mailing Address - Country:US
Mailing Address - Phone:800-660-2129
Mailing Address - Fax:
Practice Address - Street 1:626-2ND AVE S
Practice Address - Street 2:
Practice Address - City:OKANOGAN
Practice Address - State:WA
Practice Address - Zip Code:98840
Practice Address - Country:US
Practice Address - Phone:800-660-2129
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-28
Last Update Date:2023-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE613547791223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice