Provider Demographics
NPI:1437564507
Name:STEPHEN L. CHAN , D.M.D , INC.
Entity Type:Organization
Organization Name:STEPHEN L. CHAN , D.M.D , INC.
Other - Org Name:SMILEHAVEN DENTAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:L
Authorized Official - Last Name:CHAN
Authorized Official - Suffix:
Authorized Official - Credentials:DENTIST
Authorized Official - Phone:619-464-2801
Mailing Address - Street 1:4700 SPRING ST
Mailing Address - Street 2:STE. 210
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91942-0263
Mailing Address - Country:US
Mailing Address - Phone:619-464-2801
Mailing Address - Fax:619-464-2802
Practice Address - Street 1:4700 SPRING ST
Practice Address - Street 2:STE. 210
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-0263
Practice Address - Country:US
Practice Address - Phone:619-464-2801
Practice Address - Fax:619-464-2802
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-26
Last Update Date:2014-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA363451223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA514750Medicare PIN