=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659543478
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HORIZON DENTAL PRACTICE,INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/01/2008
-----------------------------------------------------
Last Update Date | 10/01/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 320 N SAN MATEO DR STE 1
-----------------------------------------------------
City | SAN MATEO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94401-2514
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 650-348-3328
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 320 N SAN MATEO DR STE 1
-----------------------------------------------------
City | SAN MATEO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94401-2514
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 650-348-3328
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SECRETARY
-----------------------------------------------------
Name | DR. LI-CHU CHEN
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 650-348-3328
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | D51910
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223P0700X
-----------------------------------------------------
Taxonomy Name | Prosthodontics
-----------------------------------------------------
License Number | D48394
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------