Provider Demographics
NPI:1154497311
Name:CHAN, JIT (DDS)
Entity Type:Individual
Prefix:DR
First Name:JIT
Middle Name:
Last Name:CHAN
Suffix:
Gender:M
Credentials:DDS
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 2722
Mailing Address - Street 2:
Mailing Address - City:GLENVIEW
Mailing Address - State:IL
Mailing Address - Zip Code:60025-6722
Mailing Address - Country:US
Mailing Address - Phone:773-762-0626
Mailing Address - Fax:
Practice Address - Street 1:3739 W 26TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60623-3827
Practice Address - Country:US
Practice Address - Phone:773-762-0626
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist