Provider Demographics
NPI:1871295352
Name:CHAN, ERIC JUSTIN
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:JUSTIN
Last Name:CHAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:370 W PLEASANTVIEW AVE STE 14A
Mailing Address - Street 2:
Mailing Address - City:HACKENSACK
Mailing Address - State:NJ
Mailing Address - Zip Code:07601-8004
Mailing Address - Country:US
Mailing Address - Phone:347-553-6278
Mailing Address - Fax:
Practice Address - Street 1:370 W PLEASANTVIEW AVE STE 14A
Practice Address - Street 2:
Practice Address - City:HACKENSACK
Practice Address - State:NJ
Practice Address - Zip Code:07601-8004
Practice Address - Country:US
Practice Address - Phone:201-305-0903
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-20
Last Update Date:2024-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NJ22DI03037300122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program