Provider Demographics
NPI:1902419864
Name:FANG, ANDRE M (DDS)
Entity type:Individual
Prefix:DR
First Name:ANDRE
Middle Name:M
Last Name:FANG
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 1:480 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:PEARL HARBOR
Mailing Address - State:HI
Mailing Address - Zip Code:96860-4908
Mailing Address - Country:US
Mailing Address - Phone:808-474-4242
Mailing Address - Fax:
Practice Address - Street 1:480 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:PEARL HARBOR
Practice Address - State:HI
Practice Address - Zip Code:96860-4908
Practice Address - Country:US
Practice Address - Phone:808-474-4242
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-28
Last Update Date:2024-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT119120719921122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist