Provider Demographics
NPI:1780741751
Name:CHAN, CLIFFORD J (DDS)
Entity type:Individual
Prefix:DR
First Name:CLIFFORD
Middle Name:J
Last Name:CHAN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9098 LAGUNA MAIN ST
Mailing Address - Street 2:SUITE #8
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95758-7449
Mailing Address - Country:US
Mailing Address - Phone:916-683-7300
Mailing Address - Fax:
Practice Address - Street 1:9098 LAGUNA MAIN ST
Practice Address - Street 2:SUITE #8
Practice Address - City:ELK GROVE
Practice Address - State:CA
Practice Address - Zip Code:95758-7449
Practice Address - Country:US
Practice Address - Phone:916-683-7300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA260441223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice