MEDICARE: DR. CHUN YU 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	22DI02232300	NJ

General Provider Information

NPI Number	:	1659356152
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CHUN YU CHAN DMD

Provider Business Mailing Address
First Line	:	7710 SIGHTSEEING RD BLDG 2826
Second Line	:	US ARMY DENTAL ACTIVITY
City	:	FORT BENNING
State	:	GA
Zip	:	31905-3764
Country	:	US
Telephone Number	:	706-544-3103
Fax Number	:

Provider Business Practice Location Address
First Line	:	7710 SIGHTSEEING RD BLDG 2826
Second Line	:	US ARMY DENTAL ACTIVITY
City	:	FORT BENNING
State	:	GA
Zip	:	31905-3764
Country	:	US
Telephone Number	:	706-544-3103
Fax Number	:

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

Provider Enumeration Date	:	12/07/2005
Last Update Date	:	06/23/2015

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