Provider Demographics
NPI:1639398977
Name:CHAN, LETI U
Entity Type:Individual
Prefix:
First Name:LETI
Middle Name:U
Last Name:CHAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LETI
Other - Middle Name:U
Other - Last Name:CHAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMD
Mailing Address - Street 1:10411 LOWER AZUSA RD
Mailing Address - Street 2:
Mailing Address - City:TEMPLE CITY
Mailing Address - State:CA
Mailing Address - Zip Code:91780-3470
Mailing Address - Country:US
Mailing Address - Phone:626-448-7433
Mailing Address - Fax:626-448-7487
Practice Address - Street 1:10411 LOWER AZUSA RD
Practice Address - Street 2:
Practice Address - City:TEMPLE CITY
Practice Address - State:CA
Practice Address - Zip Code:91780-3470
Practice Address - Country:US
Practice Address - Phone:626-448-7433
Practice Address - Fax:626-448-7487
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA306721223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice