Provider Demographics
NPI:1083901631
Name:CHAN, STACEY LEI-LING (DMD)
Entity Type:Individual
Prefix:DR
First Name:STACEY
Middle Name:LEI-LING
Last Name:CHAN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 LAKE HAYES RD STE 101
Mailing Address - Street 2:
Mailing Address - City:OVIEDO
Mailing Address - State:FL
Mailing Address - Zip Code:32765-9097
Mailing Address - Country:US
Mailing Address - Phone:407-845-9000
Mailing Address - Fax:407-809-5668
Practice Address - Street 1:101 LAKE HAYES RD STE 101
Practice Address - Street 2:
Practice Address - City:OVIEDO
Practice Address - State:FL
Practice Address - Zip Code:32765-9097
Practice Address - Country:US
Practice Address - Phone:407-845-9000
Practice Address - Fax:407-809-5668
Is Sole Proprietor?:No
Enumeration Date:2011-07-05
Last Update Date:2018-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN196731223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice