Provider Demographics
NPI:1063493658
Name:CHAN, CRAIG A (DDS)
Entity Type:Individual
Prefix:DR
First Name:CRAIG
Middle Name:A
Last Name:CHAN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:761 GARDEN VIEW CT
Mailing Address - Street 2:SUITE 103
Mailing Address - City:ENCINITAS
Mailing Address - State:CA
Mailing Address - Zip Code:92024-2400
Mailing Address - Country:US
Mailing Address - Phone:760-436-7660
Mailing Address - Fax:
Practice Address - Street 1:761 GARDEN VIEW CT
Practice Address - Street 2:SUITE 103
Practice Address - City:ENCINITAS
Practice Address - State:CA
Practice Address - Zip Code:92024-2400
Practice Address - Country:US
Practice Address - Phone:760-436-7660
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADN319031223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAT95658Medicare UPIN