Provider Demographics
NPI:1598394116
Name:JAMES, FANCHON ANTOINETTE
Entity type:Individual
Prefix:
First Name:FANCHON
Middle Name:ANTOINETTE
Last Name:JAMES
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 1:14501 NW 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33168-4105
Mailing Address - Country:US
Mailing Address - Phone:786-657-9150
Mailing Address - Fax:
Practice Address - Street 1:4330 W BROWARD BLVD STE T
Practice Address - Street 2:
Practice Address - City:PLANTATION
Practice Address - State:FL
Practice Address - Zip Code:33317-3754
Practice Address - Country:US
Practice Address - Phone:954-587-1800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-06
Last Update Date:2020-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN249681223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice