Provider Demographics
NPI:1992295646
Name:TIAN, FUCONG (BDS, PHD)
Entity type:Individual
Prefix:DR
First Name:FUCONG
Middle Name:
Last Name:TIAN
Suffix:
Gender:M
Credentials:BDS, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1612 HUGUENOT ROAD
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23113
Mailing Address - Country:US
Mailing Address - Phone:804-794-9789
Mailing Address - Fax:804-419-1059
Practice Address - Street 1:12040 W BROAD STREET
Practice Address - Street 2:
Practice Address - City:HENRICO
Practice Address - State:VA
Practice Address - Zip Code:23233
Practice Address - Country:US
Practice Address - Phone:804-364-7010
Practice Address - Fax:706-721-6778
Is Sole Proprietor?:No
Enumeration Date:2018-05-17
Last Update Date:2024-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE611715591223E0200X
TX379461223E0200X
GADNF0004341223E0200X
VA04014183751223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZX0434Medicaid
GA003241248AMedicaid