Provider Demographics
NPI:1205401866
Name:CHAN, CHI LOK TIFFANY (DDS)
Entity Type:Individual
Prefix:
First Name:CHI LOK TIFFANY
Middle Name:
Last Name:CHAN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4210 BROOKE CT UNIT 1006
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92122-5359
Mailing Address - Country:US
Mailing Address - Phone:310-729-8105
Mailing Address - Fax:
Practice Address - Street 1:455 E COLUMBIA ST
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90806-1602
Practice Address - Country:US
Practice Address - Phone:562-933-3141
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-25
Last Update Date:2023-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1064701223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry