Provider Demographics
NPI:1508419797
Name:CHAN, GREGORY (DDS)
Entity Type:Individual
Prefix:
First Name:GREGORY
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 1:19736 AUBURN DR
Mailing Address - Street 2:
Mailing Address - City:CUPERTINO
Mailing Address - State:CA
Mailing Address - Zip Code:95014-2414
Mailing Address - Country:US
Mailing Address - Phone:408-221-2203
Mailing Address - Fax:
Practice Address - Street 1:8211 BRUCEVILLE RD STE 155
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95823-2313
Practice Address - Country:US
Practice Address - Phone:916-525-7635
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-17
Last Update Date:2022-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN18584421223G0001X, 1223P0300X
CADDS1073681223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
No1223G0001XDental ProvidersDentistGeneral Practice