Provider Demographics
NPI:1265536726
Name:CHAN, ANGELINE Y (DDS, CAGS)
Entity type:Individual
Prefix:
First Name:ANGELINE
Middle Name:Y
Last Name:CHAN
Suffix:
Gender:F
Credentials:DDS, CAGS
Other - Prefix:
Other - First Name:ANGELINE
Other - Middle Name:Y
Other - Last Name:CHAN-KOSIE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS, CAGS
Mailing Address - Street 1:18 DAY ST
Mailing Address - Street 2:APT 312
Mailing Address - City:SOMERVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02144-2806
Mailing Address - Country:US
Mailing Address - Phone:920-217-1751
Mailing Address - Fax:
Practice Address - Street 1:618 CHURCH ST
Practice Address - Street 2:SUITE 520
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37219-2428
Practice Address - Country:US
Practice Address - Phone:615-750-0323
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-12
Last Update Date:2011-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI60391223G0001X
MA214061223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33801500Medicaid