Provider Demographics
NPI:1689405888
Name:CHAN, OWEN TOBIAS (DDS)
Entity type:Individual
Prefix:DR
First Name:OWEN
Middle Name:TOBIAS
Last Name:CHAN
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 1:1004 WOODBURY RD UNIT 102
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:CA
Mailing Address - Zip Code:94549-4171
Mailing Address - Country:US
Mailing Address - Phone:925-787-0853
Mailing Address - Fax:
Practice Address - Street 1:1860 ALCATRAZ AVE
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94703-2715
Practice Address - Country:US
Practice Address - Phone:510-981-4100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-09
Last Update Date:2024-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA110513122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist