MEDICARE: SUSIE T CHAN DDS A PROFESSIONAL DENTAL CORPORTATION

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	261QD0000X	Dental Clinic/Center	57743	CA

General Provider Information

NPI Number	:	1134473408
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUSIE T CHAN DDS A PROFESSIONAL DENTAL CORPORTATION

Provider Business Mailing Address
First Line	:	16918 DOVE CANYON RD
Second Line	:	STE 201
City	:	SAN DIEGO
State	:	CA
Zip	:	92127-3501
Country	:	US
Telephone Number	:	858-924-1000
Fax Number	:

Provider Business Practice Location Address
First Line	:	16918 DOVE CANYON RD
Second Line	:	STE 201
City	:	SAN DIEGO
State	:	CA
Zip	:	92127-3501
Country	:	US
Telephone Number	:	858-924-1000
Fax Number	:

Authorized Official
Title or Position	:	DENTIST
Name	:	DR. SUSIE T RO
Credential	:	DDS
Telephone Number	:	714-421-0430

Provider Enumeration Date	:	11/07/2012
Last Update Date	:	11/07/2012

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