Provider Demographics
NPI:1356638597
Name:CHAN, STEPHEN (DDS)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
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 1:3973 STEIN CT
Mailing Address - Street 2:
Mailing Address - City:SOUTH SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94080-3948
Mailing Address - Country:US
Mailing Address - Phone:408-410-4276
Mailing Address - Fax:
Practice Address - Street 1:1425 MONTGOMERY RD
Practice Address - Street 2:
Practice Address - City:RED BLUFF
Practice Address - State:CA
Practice Address - Zip Code:96080-4605
Practice Address - Country:US
Practice Address - Phone:530-528-8600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-08
Last Update Date:2016-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA599481223G0001X
AZD95751223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
No1223G0001XDental ProvidersDentistGeneral Practice