Provider Demographics
NPI:1013483981
Name:CHAN ORTHODONTIC DENTISTRY LLC
Entity Type:Organization
Organization Name:CHAN ORTHODONTIC DENTISTRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BOOKKEEPER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TINA
Authorized Official - Middle Name:
Authorized Official - Last Name:MATOS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:401-334-3070
Mailing Address - Street 1:2359 MENDON RD
Mailing Address - Street 2:
Mailing Address - City:CUMBERLAND
Mailing Address - State:RI
Mailing Address - Zip Code:02864-3707
Mailing Address - Country:US
Mailing Address - Phone:401-334-3070
Mailing Address - Fax:401-334-9031
Practice Address - Street 1:2359 MENDON RD
Practice Address - Street 2:
Practice Address - City:CUMBERLAND
Practice Address - State:RI
Practice Address - Zip Code:02864-3707
Practice Address - Country:US
Practice Address - Phone:401-334-3070
Practice Address - Fax:401-334-9031
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WILLIAM B. CHAN DMD, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-10-18
Last Update Date:2018-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty