Provider Demographics
NPI:1073128427
Name:CHAN, MICHAEL (DMD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:CHAN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3013
Mailing Address - Street 2:
Mailing Address - City:PALOS VERDES PENINSULA
Mailing Address - State:CA
Mailing Address - Zip Code:90274-9013
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:827 DEEP VALLEY DR STE 206
Practice Address - Street 2:
Practice Address - City:ROLLING HILLS ESTATES
Practice Address - State:CA
Practice Address - Zip Code:90274-3654
Practice Address - Country:US
Practice Address - Phone:310-428-5861
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-12
Last Update Date:2022-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1055051223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice