Provider Demographics
NPI:1912108564
Name:CHAN, SIU W (DDS)
Entity Type:Individual
Prefix:
First Name:SIU
Middle Name:W
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 1:2323 NORIEGA ST
Mailing Address - Street 2:SUITE 208
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94122-4259
Mailing Address - Country:US
Mailing Address - Phone:415-759-7888
Mailing Address - Fax:415-759-7890
Practice Address - Street 1:2323 NORIEGA ST
Practice Address - Street 2:SUITE 208
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94122-4259
Practice Address - Country:US
Practice Address - Phone:415-759-7888
Practice Address - Fax:415-759-7890
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA385041223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB38504Medicare ID - Type Unspecified