Provider Demographics
NPI:1730070863
Name:FAN, JACK ZHONGXU (DMD)
Entity type:Individual
Prefix:DR
First Name:JACK
Middle Name:ZHONGXU
Last Name:FAN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25501 BRAINARD AVENUE
Mailing Address - Street 2:
Mailing Address - City:FORT EISENHOWER
Mailing Address - State:GA
Mailing Address - Zip Code:30905
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:FORT EISENHOWER DENTAC
Practice Address - Street 2:BLDG 38717
Practice Address - City:APO
Practice Address - State:AA
Practice Address - Zip Code:30905
Practice Address - Country:US
Practice Address - Phone:801-647-5392
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-07-15
Last Update Date:2025-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT14224225-9926122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist