Provider Demographics
NPI:1164865242
Name:CHAN, CHRISTOPHER (DDS, MD)
Entity Type:Individual
Prefix:DR
First Name:CHRISTOPHER
Middle Name:
Last Name:CHAN
Suffix:
Gender:M
Credentials:DDS, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1512 S MARGUERITA AVE
Mailing Address - Street 2:
Mailing Address - City:ALHAMBRA
Mailing Address - State:CA
Mailing Address - Zip Code:91803-3143
Mailing Address - Country:US
Mailing Address - Phone:310-886-9863
Mailing Address - Fax:
Practice Address - Street 1:212 S EL MOLINO AVE
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91101-6501
Practice Address - Country:US
Practice Address - Phone:626-792-3161
Practice Address - Fax:626-792-9442
Is Sole Proprietor?:No
Enumeration Date:2013-04-09
Last Update Date:2022-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADDS640071223S0112X, 1223S0112X
NVS2-176C1223S0112X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty