Healthcare Provider Details

I. General information

NPI: 1568504272
Provider Name (Legal Business Name): CYNTHIA M CHAN D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/12/2007
Last Update Date: 02/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3131 O ST
LINCOLN NE
68510-1534
US

IV. Provider business mailing address

3131 O ST
LINCOLN NE
68510-1534
US

V. Phone/Fax

Practice location:
  • Phone: 402-441-8014
  • Fax:
Mailing address:
  • Phone: 916-591-2148
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number6017
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: