MEDICARE: THE PETERSON-CHAN DENTAL GROUP

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	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1225274764
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE PETERSON-CHAN DENTAL GROUP

Provider Business Mailing Address
First Line	:	5277 COLLEGE AVE #203
Second Line	:
City	:	OAKLAND
State	:	CA
Zip	:	94618-1437
Country	:	US
Telephone Number	:	510-654-2226
Fax Number	:	510-595-1455

Provider Business Practice Location Address
First Line	:	5277 COLLEGE AVE #203
Second Line	:
City	:	OAKLAND
State	:	CA
Zip	:	94618-1437
Country	:	US
Telephone Number	:	510-654-2226
Fax Number	:	510-595-1455

Authorized Official
Title or Position	:	OWNER
Name	:	DR. MELINDA JEAN CHAN
Credential	:	DDS
Telephone Number	:	510-654-2226

Provider Enumeration Date	:	01/06/2009
Last Update Date	:	01/06/2009

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