Healthcare Provider Details

I. General information

NPI: 1396250353
Provider Name (Legal Business Name): OMEGA FAMILY DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/12/2017
Last Update Date: 12/12/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

816 W WILLOW ST
LONG BEACH CA
90806-2837
US

IV. Provider business mailing address

816 W WILLOW ST
LONG BEACH CA
90806-2837
US

V. Phone/Fax

Practice location:
  • Phone: 562-595-7077
  • Fax: 562-490-4727
Mailing address:
  • Phone: 562-595-7077
  • Fax: 562-490-4727

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number44153
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number46396
License Number StateCA

VIII. Authorized Official

Name: DR. TED CHAN
Title or Position: DOCTOR
Credential:
Phone: 562-595-7077