Healthcare Provider Details

I. General information

NPI: 1538796024
Provider Name (Legal Business Name): VANIA JUJU CHAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/24/2020
Last Update Date: 08/15/2026
Certification Date: 08/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3737 MURPHY CANYON RD STE C-2
SAN DIEGO CA
92123-4454
US

IV. Provider business mailing address

PO BOX 1894
DANVILLE CA
94526-6894
US

V. Phone/Fax

Practice location:
  • Phone: 626-898-5815
  • Fax:
Mailing address:
  • Phone: 626-898-5815
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number105626
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: