Provider Demographics
NPI:1588210280
Name:CHAN, JANICE KIMBERLY (DDS)
Entity Type:Individual
Prefix:DR
First Name:JANICE
Middle Name:KIMBERLY
Last Name:CHAN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3310 CLEARFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:CA
Mailing Address - Zip Code:94803-2533
Mailing Address - Country:US
Mailing Address - Phone:510-375-1740
Mailing Address - Fax:
Practice Address - Street 1:3045 TELEGRAPH AVE STE 1
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94705-2029
Practice Address - Country:US
Practice Address - Phone:510-549-0644
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-18
Last Update Date:2022-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20200140701223G0001X
CA104182122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice