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General NPI Number Information
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NPI Number | 1407267446
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Entity Type | Individual
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Provider Name | DR. IVAN CHICCHON
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Gender | Male
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Dates
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Enumeration Date | 05/13/2014
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Last Update Date | 11/08/2018
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Provider Practice Location Address
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Address Line | 3555 DEER PARK DR
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City | STOCKTON
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State | CA
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Zip | 95219-2377
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Country | US
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Telephone | 209-242-2977
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Fax |
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Provider Business Mailing Address
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Address Line | 3555 DEER PARK DR STE 160
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City | STOCKTON
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State | CA
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Zip | 95219-2378
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Country | US
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Telephone | 209-403-5302
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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 | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 63231
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 2901021186
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License Number State | MI
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