Provider Demographics
NPI:1508185273
Name:CHAN, LISA S
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:S
Last Name:CHAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1551 OCEAN AVE STE 260
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90401-2112
Mailing Address - Country:US
Mailing Address - Phone:310-395-2345
Mailing Address - Fax:
Practice Address - Street 1:1551 OCEAN AVE STE 260
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90401-2112
Practice Address - Country:US
Practice Address - Phone:310-395-2345
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-20
Last Update Date:2010-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA034940122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist