Provider Demographics
NPI:1467991232
Name:CHAN, BERT (DDS)
Entity Type:Individual
Prefix:DR
First Name:BERT
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 1:2034 71ST ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11204-5801
Mailing Address - Country:US
Mailing Address - Phone:718-259-4345
Mailing Address - Fax:
Practice Address - Street 1:4002 US HIGHWAY 9
Practice Address - Street 2:
Practice Address - City:MORGANVILLE
Practice Address - State:NJ
Practice Address - Zip Code:07751-1577
Practice Address - Country:US
Practice Address - Phone:732-970-0900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-14
Last Update Date:2022-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0419001223G0001X
NJ22DI028752001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice