Provider Demographics
NPI:1730469883
Name:CHAN, FONG YAN DIANA (DDS)
Entity type:Individual
Prefix:
First Name:FONG YAN
Middle Name:DIANA
Last Name:CHAN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:771 SACRAMENTO ST
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94108-2504
Mailing Address - Country:US
Mailing Address - Phone:415-362-3388
Mailing Address - Fax:
Practice Address - Street 1:771 SACRAMENTO ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94108-2504
Practice Address - Country:US
Practice Address - Phone:415-362-3388
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-22
Last Update Date:2012-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA606151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice