Provider Demographics
NPI:1255784161
Name:CHAN, LATISHA (DDS)
Entity type:Individual
Prefix:DR
First Name:LATISHA
Middle Name:
Last Name:CHAN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1826 NORIEGA ST
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94122-4324
Mailing Address - Country:US
Mailing Address - Phone:415-566-8908
Mailing Address - Fax:
Practice Address - Street 1:1826 NORIEGA ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94122-4324
Practice Address - Country:US
Practice Address - Phone:415-566-8908
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-14
Last Update Date:2022-03-05
Deactivation Date:2018-03-16
Deactivation Code:
Reactivation Date:2018-03-21
Provider Licenses
StateLicense IDTaxonomies
CA101720122300000X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist