Provider Demographics
NPI:1922027440
Name:CHAN, VON (DDS, INC)
Entity Type:Individual
Prefix:DR
First Name:VON
Middle Name:
Last Name:CHAN
Suffix:
Gender:F
Credentials:DDS, INC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1416 PROFESSIONAL DR
Mailing Address - Street 2:STE. #201
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94954-5108
Mailing Address - Country:US
Mailing Address - Phone:707-763-2682
Mailing Address - Fax:707-763-4998
Practice Address - Street 1:1416 PROFESSIONAL DR
Practice Address - Street 2:STE. #201
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94954-5108
Practice Address - Country:US
Practice Address - Phone:707-763-2682
Practice Address - Fax:707-763-4998
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2008-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA466501223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice