Provider Demographics
NPI:1083771422
Name:PHYLLIS CHEN
Entity Type:Organization
Organization Name:PHYLLIS CHEN
Other - Org Name:MISSION TERRACE DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PHYLLIS
Authorized Official - Middle Name:
Authorized Official - Last Name:CHEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:415-586-3155
Mailing Address - Street 1:1794 SAN JOSE AVE
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94112-1955
Mailing Address - Country:US
Mailing Address - Phone:415-586-3155
Mailing Address - Fax:
Practice Address - Street 1:1794 SAN JOSE AVE
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94112-1955
Practice Address - Country:US
Practice Address - Phone:415-586-3155
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-03
Last Update Date:2008-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA46570122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty