Provider Demographics
NPI:1396081014
Name:CHEN, DERRICK
Entity type:Individual
Prefix:
First Name:DERRICK
Middle Name:
Last Name:CHEN
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 1:3560 PEACHTREE INDUSTRIAL BLVD
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30096-4817
Mailing Address - Country:US
Mailing Address - Phone:678-584-9266
Mailing Address - Fax:678-584-1424
Practice Address - Street 1:3560 PEACHTREE INDUSTRIAL BLVD
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096-4817
Practice Address - Country:US
Practice Address - Phone:678-584-9266
Practice Address - Fax:678-584-1424
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-28
Last Update Date:2025-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN15573122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist