Healthcare Provider Details

I. General information

NPI: 1104185784
Provider Name (Legal Business Name): WAI CHAN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2012
Last Update Date: 07/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6245 N FRESNO ST STE 103
FRESNO CA
93710
US

IV. Provider business mailing address

6245 N FRESNO ST STE 103
FRESNO CA
93710-5270
US

V. Phone/Fax

Practice location:
  • Phone: 559-554-9999
  • Fax:
Mailing address:
  • Phone: 559-554-9999
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number056876
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberR670
License Number StateMN
# 3
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberDDS103801
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: