MEDICARE: DR. MICHAEL CHAN DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	105505	CA

General Provider Information

NPI Number	:	1073128427
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MICHAEL CHAN DMD

Provider Business Mailing Address
First Line	:	PO BOX 3013
Second Line	:
City	:	PALOS VERDES PENINSULA
State	:	CA
Zip	:	90274-9013
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	827 DEEP VALLEY DR STE 206
Second Line	:
City	:	ROLLING HILLS ESTATES
State	:	CA
Zip	:	90274-3654
Country	:	US
Telephone Number	:	310-428-5861
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/12/2020
Last Update Date	:	10/10/2022

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