Healthcare Provider Details

I. General information

NPI: 1356638597
Provider Name (Legal Business Name): STEPHEN CHAN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2011
Last Update Date: 12/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1425 MONTGOMERY RD
RED BLUFF CA
96080-4605
US

IV. Provider business mailing address

3973 STEIN CT
SOUTH SAN FRANCISCO CA
94080-3948
US

V. Phone/Fax

Practice location:
  • Phone: 530-528-8600
  • Fax:
Mailing address:
  • Phone: 408-410-4276
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number59948
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberD9575
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: