Healthcare Provider Details

I. General information

NPI: 1740800614
Provider Name (Legal Business Name): CHANDENTAL PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/21/2020
Last Update Date: 04/21/2020
Certification Date: 04/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4427 S RURAL RD STE 2
TEMPE AZ
85282-7061
US

IV. Provider business mailing address

4427 S RURAL RD STE 2
TEMPE AZ
85282-7061
US

V. Phone/Fax

Practice location:
  • Phone: 480-897-2274
  • Fax:
Mailing address:
  • Phone: 480-897-2274
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JEREMY CHAN
Title or Position: OWNER
Credential: DDS
Phone: 602-448-9443