Provider Demographics
NPI:1407267446
Name:CHICCHON, IVAN
Entity Type:Individual
Prefix:DR
First Name:IVAN
Middle Name:
Last Name:CHICCHON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3555 DEER PARK DR STE 160
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95219-2378
Mailing Address - Country:US
Mailing Address - Phone:209-403-5302
Mailing Address - Fax:
Practice Address - Street 1:3555 DEER PARK DR
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95219-2377
Practice Address - Country:US
Practice Address - Phone:209-242-2977
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-13
Last Update Date:2018-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA632311223G0001X
MI29010211861223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice