Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223S0112X | Oral and Maxillofacial Surgeon | DN31903 | CA |
NPI | 1063493658 |
---|---|
Provider Name | Dr. Craig A Chan |
First Address | Encinitas, CA 92024-2400 |
Second Address | Encinitas, CA 92024-2400 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 10/11/2005 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
T95658 | (02) | CA |