Healthcare Provider Details

I. General information

NPI: 1134410244
Provider Name (Legal Business Name): WAIYIN CHAN D.M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/23/2011
Last Update Date: 07/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11360 DALBY PL
SAN DIEGO CA
92126-1512
US

IV. Provider business mailing address

11360 DALBY PL
SAN DIEGO CA
92126-1512
US

V. Phone/Fax

Practice location:
  • Phone: 858-229-6927
  • Fax:
Mailing address:
  • Phone: 858-229-6927
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number62215
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: