Provider Demographics
NPI:1083083323
Name:CHAN, MICAH (DMD, MS)
Entity Type:Individual
Prefix:DR
First Name:MICAH
Middle Name:
Last Name:CHAN
Suffix:
Gender:M
Credentials:DMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8301 STANLEY RD
Mailing Address - Street 2:APT #114
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55437-1282
Mailing Address - Country:US
Mailing Address - Phone:612-910-6203
Mailing Address - Fax:
Practice Address - Street 1:6601 LYNDALE AVE S
Practice Address - Street 2:
Practice Address - City:RICHFIELD
Practice Address - State:MN
Practice Address - Zip Code:55423-2477
Practice Address - Country:US
Practice Address - Phone:612-243-9357
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-16
Last Update Date:2015-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNS991223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics