Provider Demographics
NPI:1225233687
Name:CHAN, SELINA (DDS)
Entity type:Individual
Prefix:
First Name:SELINA
Middle Name:
Last Name:CHAN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:SELINA
Other - Middle Name:WING-LAM
Other - Last Name:CHAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:962 SAN PATRICIO DR
Mailing Address - Street 2:
Mailing Address - City:MONTEREY PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91755-5835
Mailing Address - Country:US
Mailing Address - Phone:626-379-3575
Mailing Address - Fax:
Practice Address - Street 1:10470 FOOTHILL BLVD
Practice Address - Street 2:SUITE 126
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-3754
Practice Address - Country:US
Practice Address - Phone:909-989-7888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-17
Last Update Date:2008-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS-0368851223E0200X
CA538991223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics