MEDICARE: DR. CLIFFORD J 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	26044	CA

General Provider Information

NPI Number	:	1780741751
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CLIFFORD J CHAN D.D.S.

Provider Business Mailing Address
First Line	:	9098 LAGUNA MAIN ST
Second Line	:	SUITE #8
City	:	ELK GROVE
State	:	CA
Zip	:	95758-7449
Country	:	US
Telephone Number	:	916-683-7300
Fax Number	:

Provider Business Practice Location Address
First Line	:	9098 LAGUNA MAIN ST
Second Line	:	SUITE #8
City	:	ELK GROVE
State	:	CA
Zip	:	95758-7449
Country	:	US
Telephone Number	:	916-683-7300
Fax Number	:

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

Provider Enumeration Date	:	01/02/2007
Last Update Date	:	07/08/2007

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