Provider Demographics
NPI:1083124184
Name:CHANIN, SIMON
Entity Type:Individual
Prefix:
First Name:SIMON
Middle Name:
Last Name:CHANIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:137 E GE PATTERSON AVE APT 102
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38103-4500
Mailing Address - Country:US
Mailing Address - Phone:901-626-9480
Mailing Address - Fax:
Practice Address - Street 1:3071 KIRBY WHITTEN RD
Practice Address - Street 2:
Practice Address - City:BARTLETT
Practice Address - State:TN
Practice Address - Zip Code:38134-2822
Practice Address - Country:US
Practice Address - Phone:901-382-1564
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-03
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR00000390200000X
TNDS00000111861223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program