Provider Demographics
NPI:1043237589
Name:CHAN, KERRY LIZA (DDS)
Entity Type:Individual
Prefix:DR
First Name:KERRY
Middle Name:LIZA
Last Name:CHAN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22554 VENTURA BLVD
Mailing Address - Street 2:#127
Mailing Address - City:WOODLAND HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91364-1413
Mailing Address - Country:US
Mailing Address - Phone:818-225-7883
Mailing Address - Fax:818-225-7852
Practice Address - Street 1:22554 VENTURA BLVD
Practice Address - Street 2:#127
Practice Address - City:WOODLAND HILLS
Practice Address - State:CA
Practice Address - Zip Code:91364-1413
Practice Address - Country:US
Practice Address - Phone:818-225-7883
Practice Address - Fax:818-225-7852
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADG332591223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice