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General NPI Number Information
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NPI Number | 1134473408
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Entity Type | Organization
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Legal Business Name | SUSIE T CHAN DDS A PROFESSIONAL DENTAL CORPORTATION
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Dates
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Enumeration Date | 11/07/2012
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Last Update Date | 11/07/2012
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Provider Practice Location Address
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Address Line | 16918 DOVE CANYON RD STE 201
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City | SAN DIEGO
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State | CA
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Zip | 92127-3501
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Country | US
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Telephone | 858-924-1000
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Fax |
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Provider Business Mailing Address
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Address Line | 16918 DOVE CANYON RD STE 201
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City | SAN DIEGO
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State | CA
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Zip | 92127-3501
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Country | US
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Telephone | 858-924-1000
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Fax |
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Authorized Official
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Title or Position | DENTIST
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Name | DR. SUSIE T RO
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Credential | DDS
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Telephone | 714-421-0430
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | 57743
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License Number State | CA
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