=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396081014
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DERRICK CHEN
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/28/2012
-----------------------------------------------------
Last Update Date | 09/08/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3560 PEACHTREE INDUSTRIAL BLVD
-----------------------------------------------------
City | DULUTH
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30096-4817
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-584-9266
-----------------------------------------------------
Fax | 678-584-1424
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3560 PEACHTREE INDUSTRIAL BLVD
-----------------------------------------------------
City | DULUTH
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30096-4817
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-584-9266
-----------------------------------------------------
Fax | 678-584-1424
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | DN15573
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------