Provider Demographics
NPI:1417245242
Name:CHAN, GREGG
Entity Type:Individual
Prefix:
First Name:GREGG
Middle Name:
Last Name:CHAN
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 1:23332 HAWTHORNE BLVD STE 102
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90505-3766
Mailing Address - Country:US
Mailing Address - Phone:310-791-9991
Mailing Address - Fax:
Practice Address - Street 1:23332 HAWTHORNE BLVD STE 102
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-3766
Practice Address - Country:US
Practice Address - Phone:310-791-9991
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-13
Last Update Date:2012-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD35371223G0001X
CA614101223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice