MEDICARE: ESTEBAN CHAN DMD LLC

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	DI02076102	NJ

General Provider Information

NPI Number	:	1548477417
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ESTEBAN CHAN DMD LLC

Provider Business Mailing Address
First Line	:	19 HERITAGE DR
Second Line	:
City	:	EDISON
State	:	NJ
Zip	:	08820-1632
Country	:	US
Telephone Number	:	908-757-4329
Fax Number	:

Provider Business Practice Location Address
First Line	:	12 S HOLMDEL RD
Second Line	:
City	:	HOLMDEL
State	:	NJ
Zip	:	07733-2130
Country	:	US
Telephone Number	:	732-946-4644
Fax Number	:

Authorized Official
Title or Position	:	DOCTOR
Name	:	DR. ESTEBAN CHAN
Credential	:	DMD
Telephone Number	:	732-946-4644

Provider Enumeration Date	:	05/17/2007
Last Update Date	:	08/22/2020

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