Healthcare Provider Details

I. General information

NPI: 1689405888
Provider Name (Legal Business Name): OWEN TOBIAS CHAN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2024
Last Update Date: 08/09/2024
Certification Date: 08/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1860 ALCATRAZ AVE
BERKELEY CA
94703-2715
US

IV. Provider business mailing address

1004 WOODBURY RD UNIT 102
LAFAYETTE CA
94549-4171
US

V. Phone/Fax

Practice location:
  • Phone: 510-981-4100
  • Fax:
Mailing address:
  • Phone: 925-787-0853
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number110513
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: