Provider Demographics
NPI:1356952071
Name:CHICCHON- CANTON, ANDREA (DMD)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:CHICCHON- CANTON
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8623 CAREY CT
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95212-1404
Mailing Address - Country:US
Mailing Address - Phone:209-938-7557
Mailing Address - Fax:
Practice Address - Street 1:2363 W MARCH LN
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-5239
Practice Address - Country:US
Practice Address - Phone:209-952-3951
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-14
Last Update Date:2020-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA105083122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist