Provider Demographics
NPI:1043313570
Name:CHAN, SUSAN (DDS)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:
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 1:112 LA CASA VIA STE 120
Mailing Address - Street 2:
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94598-3056
Mailing Address - Country:US
Mailing Address - Phone:925-933-7668
Mailing Address - Fax:
Practice Address - Street 1:112 LA CASA VIA STE 120
Practice Address - Street 2:
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94598-3056
Practice Address - Country:US
Practice Address - Phone:925-933-7668
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2019-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA41003122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist