Provider Demographics
NPI:1417004276
Name:CHAO, TIMOTHY
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
Last Name:CHAO
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 1:4501 E CHAPMAN AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92869-4160
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4501 E CHAPMAN AVE
Practice Address - Street 2:SUITE B
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92869-4160
Practice Address - Country:US
Practice Address - Phone:714-538-6566
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAB44848122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB44848Medicaid