Provider Demographics
NPI:1952830002
Name:CHAN, WILSON (DMD)
Entity Type:Individual
Prefix:DR
First Name:WILSON
Middle Name:
Last Name:CHAN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1233 LOCUST ST FL 3
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-5400
Mailing Address - Country:US
Mailing Address - Phone:215-985-4448
Mailing Address - Fax:215-732-1478
Practice Address - Street 1:1207 CHESTNUT ST 4TH FLOOR
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-4131
Practice Address - Country:US
Practice Address - Phone:215-525-3046
Practice Address - Fax:215-567-1617
Is Sole Proprietor?:No
Enumeration Date:2017-06-11
Last Update Date:2020-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS041841122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1036229380001Medicaid