Active NPI
Jack Fan, DDS
- General Practice Dentistry
- Austin, TX
National Provider Identifier
1831455955
On this page
Key facts
NPPES NPI Registry- Primary specialty
- General Practice Dentistry
- License
- 28806
- Practice address
- 4301 W William Cannon Dr
BLDG B, Suite 240
Austin, TX 78749-1473 - Phone
- (512) 892-7800
- Fax
- (512) 892-7805
- NPI assigned
- Apr 3, 2012
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| General Practice Dentistry | 1223G0001X | 28806 | TX | Primary |
Addresses
Primary practice location
4301 W William Cannon Dr
BLDG B, Suite 240
Austin, TX 78749-1473
Mailing address
4301 W William Cannon Dr
BLDG B, Suite 240
Austin, TX 78749-1473
Phone (512) 892-7800
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| TX 28806 | Other | TX | TX LICENSE |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1333411200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1478649600000",
"number": "1831455955",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "4301 W WILLIAM CANNON DR",
"address_2": "BLDG B, SUITE 240",
"city": "AUSTIN",
"state": "TX",
"postal_code": "787491473",
"telephone_number": "512-892-7800",
"fax_number": "512-892-7805"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "4301 W WILLIAM CANNON DR",
"address_2": "BLDG B, SUITE 240",
"city": "AUSTIN",
"state": "TX",
"postal_code": "787491473",
"telephone_number": "512-892-7800",
"fax_number": "512-892-7805"
}
],
"practiceLocations": [],
"basic": {
"last_name": "FAN",
"first_name": "JACK",
"credential": "DDS",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2012-04-03",
"last_updated": "2016-11-09",
"status": "A"
},
"taxonomies": [
{
"code": "1223G0001X",
"taxonomy_group": "",
"desc": "Dentist, General Practice",
"state": "TX",
"license": "28806",
"primary": true
}
],
"identifiers": [
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "TX LICENSE",
"identifier": "TX 28806",
"state": "TX"
}
],
"endpoints": [],
"other_names": []
}Other providers in Austin, TX
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 9, 2016; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.