Provider Demographics
NPI:1063905453
Name:FAN, ZHIYONG (DDS)
Entity type:Individual
Prefix:
First Name:ZHIYONG
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 1:16238 RR 620 N STE F194
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78717-5212
Mailing Address - Country:US
Mailing Address - Phone:713-380-8476
Mailing Address - Fax:
Practice Address - Street 1:1640 HIGHLAND FALLS DR STE 901
Practice Address - Street 2:
Practice Address - City:LEANDER
Practice Address - State:TX
Practice Address - Zip Code:78641-4841
Practice Address - Country:US
Practice Address - Phone:512-986-7196
Practice Address - Fax:512-986-7835
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-11
Last Update Date:2021-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX340071223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty