Provider Demographics
NPI:1609922442
Name:HEIDI L CHAN DDS INC
Entity Type:Organization
Organization Name:HEIDI L CHAN DDS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:HEIDI
Authorized Official - Middle Name:L
Authorized Official - Last Name:CHAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:818-709-4400
Mailing Address - Street 1:9241 RESEDA BLVD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:NORTHRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:91324
Mailing Address - Country:US
Mailing Address - Phone:818-709-4400
Mailing Address - Fax:818-709-4056
Practice Address - Street 1:9241 RESEDA BLVD
Practice Address - Street 2:SUITE 104
Practice Address - City:NORTHRIDGE
Practice Address - State:CA
Practice Address - Zip Code:91324
Practice Address - Country:US
Practice Address - Phone:818-709-4400
Practice Address - Fax:818-709-4056
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-26
Last Update Date:2016-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA46035122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB4603501Medicare ID - Type Unspecified