Provider Demographics
NPI:1720024987
Name:CHAN, TYRONE (DDS)
Entity Type:Individual
Prefix:
First Name:TYRONE
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 1:2645 OCEAN AVENUE
Mailing Address - Street 2:SUITE 302
Mailing Address - City:SAN FRANSISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94132
Mailing Address - Country:US
Mailing Address - Phone:415-333-8819
Mailing Address - Fax:209-478-6890
Practice Address - Street 1:2645 OCEAN AVENUE
Practice Address - Street 2:SUITE 302
Practice Address - City:SAN FRANSISCO
Practice Address - State:CA
Practice Address - Zip Code:94132
Practice Address - Country:US
Practice Address - Phone:415-333-8819
Practice Address - Fax:510-451-3968
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-22
Last Update Date:2018-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA403431223X0400X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics