Provider Demographics
NPI:1588002471
Name:OH, CHAN M
Entity Type:Individual
Prefix:
First Name:CHAN
Middle Name:M
Last Name:OH
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 1:9119 MIL PARK AVE
Mailing Address - Street 2:SUITE 1111
Mailing Address - City:JBLM
Mailing Address - State:WA
Mailing Address - Zip Code:98433
Mailing Address - Country:US
Mailing Address - Phone:253-966-9960
Mailing Address - Fax:
Practice Address - Street 1:9119 MIL PARK AVE
Practice Address - Street 2:SUITE 1111
Practice Address - City:JBLM
Practice Address - State:WA
Practice Address - Zip Code:98433
Practice Address - Country:US
Practice Address - Phone:253-966-9960
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-12
Last Update Date:2022-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADH60035074124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist