MEDICARE: DR. CHARLENE RENEE CHAN D.D.S., M.S.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	036066	CA

General Provider Information

NPI Number	:	1043349111
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CHARLENE RENEE CHAN D.D.S., M.S.D.

Provider Business Mailing Address
First Line	:	6800 PALM AVE
Second Line	:	SUITE B
City	:	SEBASTOPOL
State	:	CA
Zip	:	95472-4269
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6800 PALM AVE
Second Line	:	SUITE B
City	:	SEBASTOPOL
State	:	CA
Zip	:	95472-4269
Country	:	US
Telephone Number	:	707-823-1200
Fax Number	:	707-823-5363

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/05/2007
Last Update Date	:	07/08/2007

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