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General NPI Number Information
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NPI Number | 1083083323
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Entity Type | Individual
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Provider Name | MICAH CHAN D.M.D., M.S.
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Gender | Male
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Dates
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Enumeration Date | 09/16/2015
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Last Update Date | 09/16/2015
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Provider Practice Location Address
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Address Line | 6601 LYNDALE AVE S
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City | RICHFIELD
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State | MN
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Zip | 55423-2477
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Country | US
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Telephone | 612-243-9357
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Fax |
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Provider Business Mailing Address
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Address Line | 8301 STANLEY RD APT #114
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City | BLOOMINGTON
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State | MN
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Zip | 55437-1282
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Country | US
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Telephone | 612-910-6203
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0300X
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Taxonomy Name | Periodontics
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License Number | S99
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License Number State | MN
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