MEDICARE: IVY CHAN DDS

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	41328	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	41328	OTHER	CA	CA DENTIST LICENSE NUMBER

General Provider Information

NPI Number	:	1851335798
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	IVY CHAN DDS

Provider Business Mailing Address
First Line	:	2041 POLK ST
Second Line	:	SUITE G
City	:	SAN FRANCISCO
State	:	CA
Zip	:	94109-2525
Country	:	US
Telephone Number	:	415-885-5255
Fax Number	:	415-885-5256

Provider Business Practice Location Address
First Line	:	2041 POLK ST
Second Line	:	SUITE G
City	:	SAN FRANCISCO
State	:	CA
Zip	:	94109-2525
Country	:	US
Telephone Number	:	415-885-5255
Fax Number	:	415-885-5256

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

Provider Enumeration Date	:	06/14/2006
Last Update Date	:	06/30/2009

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