Provider Demographics
NPI:1336450444
Name:CHAN, ALLEN (DMD)
Entity Type:Individual
Prefix:
First Name:ALLEN
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 1:674 HAZELTON DR
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39110-7332
Mailing Address - Country:US
Mailing Address - Phone:703-501-8466
Mailing Address - Fax:
Practice Address - Street 1:82ND MEDICAL GROUP (AETC) PAS: SQ0JFB5D
Practice Address - Street 2:SHEPPARD AFB
Practice Address - City:APO
Practice Address - State:AA
Practice Address - Zip Code:76311
Practice Address - Country:US
Practice Address - Phone:210-565-0645
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-24
Last Update Date:2010-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS038318122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist