MEDICARE: DR. JACK W. CHAN DDS

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	48585	CA

General Provider Information

NPI Number	:	1891799714
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JACK W. CHAN DDS

Provider Business Mailing Address
First Line	:	818 CIVIC CENTER DR
Second Line	:
City	:	OCEANSIDE
State	:	CA
Zip	:	92054-2506
Country	:	US
Telephone Number	:	760-722-4765
Fax Number	:	790-722-0980

Provider Business Practice Location Address
First Line	:	818 CIVIC CENTER DR
Second Line	:
City	:	OCEANSIDE
State	:	CA
Zip	:	92054-2506
Country	:	US
Telephone Number	:	760-722-4765
Fax Number	:	790-722-0980

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

Provider Enumeration Date	:	06/09/2005
Last Update Date	:	07/08/2007

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