=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811232747
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DR CHEAN DDS PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/04/2012
-----------------------------------------------------
Last Update Date | 12/04/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2700 S TAMIAMI TRL SUITE 10
-----------------------------------------------------
City | SARASOTA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34239-4530
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-953-3839
-----------------------------------------------------
Fax | 941-953-3811
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2700 S TAMIAMI TRL SUITE 10
-----------------------------------------------------
City | SARASOTA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34239-4530
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-953-3839
-----------------------------------------------------
Fax | 941-953-3811
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST
-----------------------------------------------------
Name | DR. SANGCHAN CHEAN IANLENG
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 941-953-3839
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | DN 11784
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------