Provider Demographics
NPI:1942722269
Name:CHOW, VICTOR
Entity Type:Individual
Prefix:
First Name:VICTOR
Middle Name:
Last Name:CHOW
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:308 W WILSON AVE APT 632
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91203-3677
Mailing Address - Country:US
Mailing Address - Phone:718-650-1779
Mailing Address - Fax:
Practice Address - Street 1:662 S SUNSET AVE STE 102
Practice Address - Street 2:
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91790-2806
Practice Address - Country:US
Practice Address - Phone:626-337-9494
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-07
Last Update Date:2018-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA103134122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program