Healthcare Provider Details

I. General information

NPI: 1366738247
Provider Name (Legal Business Name): HSUN LIANG CHAN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2011
Last Update Date: 11/29/2023
Certification Date: 11/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 W 12TH AVE
COLUMBUS OH
43210-1267
US

IV. Provider business mailing address

305 W 12TH AVE
COLUMBUS OH
43210-1267
US

V. Phone/Fax

Practice location:
  • Phone: 614-292-1472
  • Fax: 734-763-5503
Mailing address:
  • Phone: 614-292-1472
  • Fax: 614-688-3553

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2901020453
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number71.000285
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: