MEDICARE: TYRONE 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	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	40343	CA
2	122300000X	Dentist	40343	CA

General Provider Information

NPI Number	:	1720024987
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TYRONE CHAN D.D.S.

Provider Business Mailing Address
First Line	:	2645 OCEAN AVENUE
Second Line	:	SUITE 302
City	:	SAN FRANSISCO
State	:	CA
Zip	:	94132
Country	:	US
Telephone Number	:	415-333-8819
Fax Number	:	209-478-6890

Provider Business Practice Location Address
First Line	:	2645 OCEAN AVENUE
Second Line	:	SUITE 302
City	:	SAN FRANSISCO
State	:	CA
Zip	:	94132
Country	:	US
Telephone Number	:	415-333-8819
Fax Number	:	510-451-3968

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

Provider Enumeration Date	:	06/22/2006
Last Update Date	:	04/11/2018

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