MEDICARE: DR. RAYMOND W CHAN D.D.S.

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	60703	CA

General Provider Information

NPI Number	:	1619256351
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RAYMOND W CHAN D.D.S.

Provider Business Mailing Address
First Line	:	42 WENTWORTH PL
Second Line	:
City	:	SAN FRANCISCO
State	:	CA
Zip	:	94108-1307
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	42 WENTWORTH PL
Second Line	:
City	:	SAN FRANCISCO
State	:	CA
Zip	:	94108-1307
Country	:	US
Telephone Number	:	415-986-8088
Fax Number	:

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

Provider Enumeration Date	:	08/11/2011
Last Update Date	:	02/01/2013

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