Provider Demographics
NPI:1043367147
Name:CHIN, CHARLES (DDS)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:
Last Name:CHIN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6670
Mailing Address - Street 2:
Mailing Address - City:ALHAMBRA
Mailing Address - State:CA
Mailing Address - Zip Code:91802-6670
Mailing Address - Country:US
Mailing Address - Phone:626-573-3559
Mailing Address - Fax:626-573-1247
Practice Address - Street 1:210 N GARFIELD AVE
Practice Address - Street 2:305
Practice Address - City:MONTEREY PARK
Practice Address - State:CA
Practice Address - Zip Code:91754-1746
Practice Address - Country:US
Practice Address - Phone:626-573-3559
Practice Address - Fax:626-573-1247
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA29882122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB2988201Medicaid