Brand Name | IMPLANTIUM |
Type of Device | IMPLANT, ENDOSSEOUS, ROOT-FORM |
Manufacturer (Section D) |
DENTIUM USA |
6761 katella ave. |
cypress CA 90630 |
|
Manufacturer (Section G) |
DENTIUM USA |
6761 katella ave. |
|
cypress CA 90630 |
|
Manufacturer Contact |
younjung
yuk
|
6761 katella ave. |
cypress, CA 90630
|
7142260229
|
|
MDR Report Key | 4914070 |
MDR Text Key | 6430742 |
Report Number | 3005503242-2015-00016 |
Device Sequence Number | 1 |
Product Code |
DZE
|
Combination Product (y/n) | N |
Reporter Country Code | US |
PMA/PMN Number | K041368 |
Number of Events Reported | 1 |
Summary Report (Y/N) | N |
Report Source |
Manufacturer
|
Source Type |
Health Professional |
Reporter Occupation |
Dentist
|
Type of Report
| Initial |
Report Date |
07/14/2015 |
1 Device was Involved in the Event |
|
1 Patient was Involved in the Event |
|
Is this an Adverse Event Report? |
Yes
|
Is this a Product Problem Report? |
No
|
Device Operator |
Dentist
|
Device Expiration Date | 12/31/2018 |
Device Model Number | FX3410MLC |
Device Lot Number | L06X06H07AS |
Was Device Available for Evaluation? |
Device Returned to Manufacturer
|
Date Returned to Manufacturer | 04/02/2015 |
Is the Reporter a Health Professional? |
Yes
|
Initial Date Manufacturer Received |
04/02/2015
|
Initial Date FDA Received | 07/14/2015 |
Was Device Evaluated by Manufacturer? |
Yes
|
Date Device Manufactured | 12/07/2010 |
Is the Device Single Use? |
Yes
|
Is This a Reprocessed and Reused Single-Use Device? |
No
|
Type of Device Usage |
Initial
|
Patient Sequence Number | 1 |
Patient Outcome(s) |
Required Intervention;
|
Patient Age | 57 YR |
|
|