Healthcare Provider Details

I. General information

NPI: 1295069045
Provider Name (Legal Business Name): JENNIFER M CHAN D.M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2009
Last Update Date: 12/26/2024
Certification Date: 12/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10414 BEARDSLEE BLVD STE 200
BOTHELL WA
98011-3205
US

IV. Provider business mailing address

955 POWELL AVE SW
RENTON WA
98057-2908
US

V. Phone/Fax

Practice location:
  • Phone: 425-424-6350
  • Fax:
Mailing address:
  • Phone: 425-277-1311
  • Fax: 425-277-1566

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDE60487956
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number22D102422200
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: