Provider Demographics
NPI:1720207954
Name:CHAN, WAYMAN M (DDS)
Entity Type:Individual
Prefix:DR
First Name:WAYMAN
Middle Name:M
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 1:411 E BAY STATE ST
Mailing Address - Street 2:APT 74
Mailing Address - City:ALHAMBRA
Mailing Address - State:CA
Mailing Address - Zip Code:91801-3975
Mailing Address - Country:US
Mailing Address - Phone:626-966-3033
Mailing Address - Fax:
Practice Address - Street 1:2233 E GARVEY AVE N
Practice Address - Street 2:
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91791-1500
Practice Address - Country:US
Practice Address - Phone:626-966-3033
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-25
Last Update Date:2007-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA53581122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist