Healthcare Provider Details

I. General information

NPI: 1871295352
Provider Name (Legal Business Name): ERIC JUSTIN CHAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/20/2023
Last Update Date: 09/09/2024
Certification Date: 09/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

370 W PLEASANTVIEW AVE STE 14A
HACKENSACK NJ
07601-8004
US

IV. Provider business mailing address

370 W PLEASANTVIEW AVE STE 14A
HACKENSACK NJ
07601-8004
US

V. Phone/Fax

Practice location:
  • Phone: 201-305-0903
  • Fax:
Mailing address:
  • Phone: 347-553-6278
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number22DI03037300
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: