Provider Demographics
NPI:1811079106
Name:CHAN, KENNETH KA (DDS)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:KA
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 1:1315 FAIR OAKS AVE STE 103
Mailing Address - Street 2:
Mailing Address - City:SOUTH PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91030-3868
Mailing Address - Country:US
Mailing Address - Phone:626-799-8068
Mailing Address - Fax:626-799-8069
Practice Address - Street 1:1315 FAIR OAKS AVE STE 103
Practice Address - Street 2:
Practice Address - City:SOUTH PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91030-3868
Practice Address - Country:US
Practice Address - Phone:626-799-8068
Practice Address - Fax:626-799-8069
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA47857122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist