Provider Demographics
NPI:1043406853
Name:KENNETH K. CHAN, DDS, A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:KENNETH K. CHAN, DDS, A PROFESSIONAL CORPORATION
Other - Org Name:HEALTHY SMILE FAMILY DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:KA
Authorized Official - Last Name:CHAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:626-799-8068
Mailing Address - Street 1:1315 FAIR OAKS AVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:SOUTH PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91030-3868
Mailing Address - Country:US
Mailing Address - Phone:626-799-8068
Mailing Address - Fax:626-799-8069
Practice Address - Street 1:1315 FAIR OAKS AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:SOUTH PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91030-3868
Practice Address - Country:US
Practice Address - Phone:626-799-8068
Practice Address - Fax:626-799-8069
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-15
Last Update Date:2007-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental