Healthcare Provider Details

I. General information

NPI: 1063258184
Provider Name (Legal Business Name): BARRY CHAN DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/08/2024
Last Update Date: 05/14/2026
Certification Date: 05/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2240 GRANDE BLVD SE STE 101
RIO RANCHO NM
87124-1751
US

IV. Provider business mailing address

427 ATHENS ST
SAN FRANCISCO CA
94112-2801
US

V. Phone/Fax

Practice location:
  • Phone: 505-994-1700
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDB-2026-0093
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: